Provider Demographics
NPI:1023589835
Name:STILLMAN, MARY CLAIRE (LMT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:CLAIRE
Last Name:STILLMAN
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 1:9109 N TENNYSON DR
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10134 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5700
Practice Address - Country:US
Practice Address - Phone:414-303-5915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14789-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14789-146OtherDEPARTMENT OF SAFETY & PROFESSIONAL SERVICES