Provider Demographics
NPI:1326558826
Name:DEOSARAN, STACIE REENA (LMT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:REENA
Last Name:DEOSARAN
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 1:5475 VINELAND RD APT 8107
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-7635
Mailing Address - Country:US
Mailing Address - Phone:407-932-8959
Mailing Address - Fax:
Practice Address - Street 1:5475 VINELAND RD APT 8107
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-7635
Practice Address - Country:US
Practice Address - Phone:407-932-8959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA73975225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist