Provider Demographics
NPI:1225662984
Name:STOCKBAUER, HEIDI GRACE (LMT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:GRACE
Last Name:STOCKBAUER
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 1:603 HUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-1117
Mailing Address - Country:US
Mailing Address - Phone:253-863-0855
Mailing Address - Fax:
Practice Address - Street 1:603 HUNT AVE
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1117
Practice Address - Country:US
Practice Address - Phone:253-863-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60953289225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty