Provider Demographics
NPI:1366043903
Name:BRACKEEN, STEPHANIE JANE (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JANE
Last Name:BRACKEEN
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 1:95 BASSINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-1526
Mailing Address - Country:US
Mailing Address - Phone:760-421-2303
Mailing Address - Fax:
Practice Address - Street 1:95 BASSINGHAM DR
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72715-1526
Practice Address - Country:US
Practice Address - Phone:760-421-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031998225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist