Provider Demographics
NPI:1609013564
Name:CHISHOLM, STACEY A (LMT)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:A
Last Name:CHISHOLM
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 1:2459 TIMBERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8254
Mailing Address - Country:US
Mailing Address - Phone:386-316-5313
Mailing Address - Fax:
Practice Address - Street 1:626 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-3164
Practice Address - Country:US
Practice Address - Phone:386-316-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL53499225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist