Provider Demographics
NPI:1851676431
Name:FORTE, STACY DIANE (CMT)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:DIANE
Last Name:FORTE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 E HENNEPIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2705
Mailing Address - Country:US
Mailing Address - Phone:612-331-5700
Mailing Address - Fax:
Practice Address - Street 1:2406 E HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2705
Practice Address - Country:US
Practice Address - Phone:612-331-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN/A225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist