Provider Demographics
NPI:1548776347
Name:SMITH, STEPHANE MARIE (LMT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANE
Middle Name:MARIE
Last Name:SMITH
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 1:731 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-3802
Mailing Address - Country:US
Mailing Address - Phone:920-323-6587
Mailing Address - Fax:
Practice Address - Street 1:814 JAY ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4520
Practice Address - Country:US
Practice Address - Phone:920-686-0328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-17
Last Update Date:2017-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12531-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty