Provider Demographics
NPI:1194396358
Name:STETSON, MADDISON MARCIA (LMT)
Entity Type:Individual
Prefix:
First Name:MADDISON
Middle Name:MARCIA
Last Name:STETSON
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 1:10848 169TH RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-6248
Mailing Address - Country:US
Mailing Address - Phone:386-209-6357
Mailing Address - Fax:
Practice Address - Street 1:725 SE BAYA DR STE 101
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6092
Practice Address - Country:US
Practice Address - Phone:386-280-0019
Practice Address - Fax:386-487-3740
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA95271225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist