Provider Demographics
NPI:1649402371
Name:OLIVER, STACIE HAMAI (LMT)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:HAMAI
Last Name:OLIVER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:HAMAI
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:167 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3644
Mailing Address - Country:US
Mailing Address - Phone:860-448-6766
Mailing Address - Fax:860-449-6754
Practice Address - Street 1:167 BROAD ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3644
Practice Address - Country:US
Practice Address - Phone:860-448-6766
Practice Address - Fax:860-449-6754
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003691225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist