Provider Demographics
NPI:1861533986
Name:STUBBS, BRENT CRAIG (LMT)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:CRAIG
Last Name:STUBBS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 BRAFFORTON DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-0710
Mailing Address - Country:US
Mailing Address - Phone:850-942-7003
Mailing Address - Fax:
Practice Address - Street 1:521 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2528
Practice Address - Country:US
Practice Address - Phone:850-942-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA30018225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC9013OtherBLUE CROSS BLUE SHIELD PR