Provider Demographics
NPI:1588821441
Name:WALSH, STACIE RENEE (LAC, LMT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:RENEE
Last Name:WALSH
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23023 38TH CT W
Mailing Address - Street 2:
Mailing Address - City:BRIER
Mailing Address - State:WA
Mailing Address - Zip Code:98036-8262
Mailing Address - Country:US
Mailing Address - Phone:541-806-0704
Mailing Address - Fax:
Practice Address - Street 1:23023 38TH CT W
Practice Address - Street 2:
Practice Address - City:BRIER
Practice Address - State:WA
Practice Address - Zip Code:98036-8262
Practice Address - Country:US
Practice Address - Phone:541-806-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017665225700000X
WAAC 60249633171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist