Provider Demographics
NPI:1326736554
Name:WILLIAMS, STACEY (LMT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WILLIAMS
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 1:841 E 5875 S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4997
Mailing Address - Country:US
Mailing Address - Phone:801-458-3701
Mailing Address - Fax:
Practice Address - Street 1:1480 S ORCHARD DR STE 101B
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5161
Practice Address - Country:US
Practice Address - Phone:801-458-3701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT117824-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty