Provider Demographics
NPI:1356986103
Name:CARL, STEPHANIE S (LMP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:S
Last Name:CARL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 E LARCH ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1535
Mailing Address - Country:US
Mailing Address - Phone:509-989-0122
Mailing Address - Fax:
Practice Address - Street 1:1366 E LARCH ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1535
Practice Address - Country:US
Practice Address - Phone:509-989-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61005491225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACARL-SS119OLOtherSTATE LICENSE NUMBER