Provider Demographics
NPI:1134856545
Name:STACKHOUSE, SABRINA (MT)
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SAINT MICHAELS DR APT SUITE
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-9106
Mailing Address - Country:US
Mailing Address - Phone:815-793-6354
Mailing Address - Fax:815-523-7656
Practice Address - Street 1:27 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-9106
Practice Address - Country:US
Practice Address - Phone:815-523-7656
Practice Address - Fax:815-793-6353
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
IL227017071225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty