Provider Demographics
NPI:1558667824
Name:BACQUET, STEPHANIE RACHELE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RACHELE
Last Name:BACQUET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:RACHELE
Other - Last Name:MATHEWS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5176
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-5176
Mailing Address - Country:US
Mailing Address - Phone:909-338-7185
Mailing Address - Fax:
Practice Address - Street 1:22077 MOCKINGBIRD LANE
Practice Address - Street 2:
Practice Address - City:CEDARPINES PARK
Practice Address - State:CA
Practice Address - Zip Code:92322
Practice Address - Country:US
Practice Address - Phone:909-338-7185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist