Provider Demographics
NPI:1851028435
Name:WELCH, STACEY (LMBT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WELCH
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 OLEANDER DR STE 103
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6800
Mailing Address - Country:US
Mailing Address - Phone:910-264-1580
Mailing Address - Fax:
Practice Address - Street 1:4020 OLEANDER DR STE 103
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6800
Practice Address - Country:US
Practice Address - Phone:910-264-1580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4723225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist