Provider Demographics
NPI:1740751569
Name:STAAK, SAKURA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SAKURA
Middle Name:
Last Name:STAAK
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 1:22 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2004
Mailing Address - Country:US
Mailing Address - Phone:203-685-8222
Mailing Address - Fax:
Practice Address - Street 1:2030 STRAITS TPKE STE 3
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1831
Practice Address - Country:US
Practice Address - Phone:203-685-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8961225700000X
CT133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty