Provider Demographics
NPI:1356733422
Name:GRACE, STEFAN MATTHEW (LAC)
Entity type:Individual
Prefix:MR
First Name:STEFAN
Middle Name:MATTHEW
Last Name:GRACE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:VT
Mailing Address - Zip Code:05345-9667
Mailing Address - Country:US
Mailing Address - Phone:503-913-8551
Mailing Address - Fax:
Practice Address - Street 1:20 TECHNOLOGY DR UNIT 7
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-9181
Practice Address - Country:US
Practice Address - Phone:503-913-8551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091.0125591171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1902343098OtherNPI