Provider Demographics
NPI:1679736185
Name:STONER, GLEN ALAN (BS LMT)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ALAN
Last Name:STONER
Suffix:
Gender:M
Credentials:BS LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9723
Mailing Address - Country:US
Mailing Address - Phone:407-365-1355
Mailing Address - Fax:
Practice Address - Street 1:100 EAST BROAWAY ST
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:407-365-1355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA33876225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA33876OtherMASSAGE THERAPY LICENSE