Provider Demographics
NPI:1427418987
Name:THOMPSON, STACY (LMBT)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 PLEASANT RD
Mailing Address - Street 2:#10637
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-7299
Mailing Address - Country:US
Mailing Address - Phone:704-408-1466
Mailing Address - Fax:
Practice Address - Street 1:10370 PARK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8508
Practice Address - Country:US
Practice Address - Phone:704-408-1466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15105225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist