Provider Demographics
NPI:1689131260
Name:PERBERA, STACEY ALLAN (LMT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ALLAN
Last Name:PERBERA
Suffix:
Gender:M
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:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:HAUULA
Mailing Address - State:HI
Mailing Address - Zip Code:96717-0959
Mailing Address - Country:US
Mailing Address - Phone:808-382-3875
Mailing Address - Fax:
Practice Address - Street 1:54-224B HAUULA HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:HAUULA
Practice Address - State:HI
Practice Address - Zip Code:96717-9638
Practice Address - Country:US
Practice Address - Phone:808-382-3875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-12848225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty