Provider Demographics
NPI:1205113594
Name:IRWIN, STACI DIANE (LMT)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:DIANE
Last Name:IRWIN
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 1:12650 EDINBORO RD
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-6016
Mailing Address - Country:US
Mailing Address - Phone:814-734-4541
Mailing Address - Fax:814-734-5562
Practice Address - Street 1:12650 EDINBORO RD
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-6016
Practice Address - Country:US
Practice Address - Phone:814-734-4541
Practice Address - Fax:814-734-5562
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG001363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist