Provider Demographics
NPI:1972191260
Name:DONELSON, STEPHANIE MICHELLE (LMT)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:DONELSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6179 CAMROSE LN
Mailing Address - Street 2:
Mailing Address - City:BROAD RUN
Mailing Address - State:VA
Mailing Address - Zip Code:20137-1900
Mailing Address - Country:US
Mailing Address - Phone:571-408-5545
Mailing Address - Fax:
Practice Address - Street 1:6484 MAIN ST
Practice Address - Street 2:
Practice Address - City:THE PLAINS
Practice Address - State:VA
Practice Address - Zip Code:20198-2255
Practice Address - Country:US
Practice Address - Phone:571-408-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019016407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist