Provider Demographics
NPI:1023400017
Name:STOETZER, SHANE R (LMT)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:R
Last Name:STOETZER
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 1:1401 S ARCH AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-4202
Mailing Address - Country:US
Mailing Address - Phone:330-238-3105
Mailing Address - Fax:
Practice Address - Street 1:1401 S ARCH AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4202
Practice Address - Country:US
Practice Address - Phone:330-238-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020922225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist