Provider Demographics
NPI:1184232233
Name:MACIAS, STETSON PAUL (LMT)
Entity Type:Individual
Prefix:
First Name:STETSON
Middle Name:PAUL
Last Name:MACIAS
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 1:1041 PENN CIR APT F614
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1033
Mailing Address - Country:US
Mailing Address - Phone:425-243-9190
Mailing Address - Fax:
Practice Address - Street 1:225 S HENDERSON RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2416
Practice Address - Country:US
Practice Address - Phone:610-354-0138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG012789225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty