Provider Demographics
NPI:1457841082
Name:ROBERTS, STACEY O (LMT)
Entity Type:Individual
Prefix:MR
First Name:STACEY
Middle Name:O
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S SYCAMORE ST STE 7
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-5804
Mailing Address - Country:US
Mailing Address - Phone:804-722-0317
Mailing Address - Fax:
Practice Address - Street 1:700 S SYCAMORE ST STE 7
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5804
Practice Address - Country:US
Practice Address - Phone:804-722-0317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019005592225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist