Provider Demographics
NPI:1598995425
Name:DYER, STACEY (LMT)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:DYER
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 1:712 PUTNAM PIKE
Mailing Address - Street 2:UNIT 4
Mailing Address - City:CHEPACHET
Mailing Address - State:RI
Mailing Address - Zip Code:02814-1403
Mailing Address - Country:US
Mailing Address - Phone:401-568-2200
Mailing Address - Fax:401-568-2206
Practice Address - Street 1:712 PUTNAM PIKE
Practice Address - Street 2:UNIT 4
Practice Address - City:CHEPACHET
Practice Address - State:RI
Practice Address - Zip Code:02814-1403
Practice Address - Country:US
Practice Address - Phone:401-568-2200
Practice Address - Fax:401-568-2206
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01270225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist