Provider Demographics
NPI:1376313692
Name:WILLIAMS, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10696 CARROLL WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-1317
Mailing Address - Country:US
Mailing Address - Phone:314-717-8871
Mailing Address - Fax:
Practice Address - Street 1:1524 S BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-2206
Practice Address - Country:US
Practice Address - Phone:314-472-3493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009001941225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist