Provider Demographics
NPI:1558903856
Name:MADDEN, STACEY LYN (LMBT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYN
Last Name:MADDEN
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 1:947 N SALISBURY GQ AVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-6817
Mailing Address - Country:US
Mailing Address - Phone:704-838-6165
Mailing Address - Fax:
Practice Address - Street 1:806 S SALISBURY GQ AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28146-8157
Practice Address - Country:US
Practice Address - Phone:704-838-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17380225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist