Provider Demographics
NPI:1669645289
Name:STEVENS, SHELLY (LMT, CNMT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LMT, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1781
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-1781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1150 NAKUI ST.
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768
Practice Address - Country:US
Practice Address - Phone:808-276-9630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT #6177225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist