Provider Demographics
NPI:1922375690
Name:SKAGGS, STEFANIE RENEE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:RENEE
Last Name:SKAGGS
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 1:11772 HAYLOFT LN
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8955
Mailing Address - Country:US
Mailing Address - Phone:619-399-6006
Mailing Address - Fax:
Practice Address - Street 1:5428 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7318
Practice Address - Country:US
Practice Address - Phone:779-200-5802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-24
Last Update Date:2011-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.011717225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist