Provider Demographics
NPI:1770855702
Name:STASIS, BEVERLY M (LMT)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:M
Last Name:STASIS
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 1:3444 EAST LAKE RD
Mailing Address - Street 2:SUITE 412
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684
Mailing Address - Country:US
Mailing Address - Phone:727-492-0970
Mailing Address - Fax:727-286-6204
Practice Address - Street 1:3444 EAST LAKE RD
Practice Address - Street 2:SUITE 412
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-492-0970
Practice Address - Fax:727-286-6204
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLMA57967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist