Provider Demographics
NPI:1376970764
Name:ANDERSEN, STACEY L (LAC WI#803-55/ LMT W)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:L
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:LAC WI#803-55/ LMT W
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8607 OLD GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53158
Mailing Address - Country:US
Mailing Address - Phone:262-496-5642
Mailing Address - Fax:
Practice Address - Street 1:5603 7TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140
Practice Address - Country:US
Practice Address - Phone:262-496-5642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI803-55171100000X
WI4199-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist