Provider Demographics
NPI:1255636536
Name:STONE, TAMARA ST THERESA (LMTBT)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:ST THERESA
Last Name:STONE
Suffix:
Gender:F
Credentials:LMTBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 COUNTY ROAD V
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-7205
Mailing Address - Country:US
Mailing Address - Phone:920-251-8780
Mailing Address - Fax:
Practice Address - Street 1:952 S PARK AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8041
Practice Address - Country:US
Practice Address - Phone:920-251-8780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10134-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist