Provider Demographics
NPI:1740003367
Name:HALL, STACEY ANN (LMT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:HALL
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 1:6500 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1721
Mailing Address - Country:US
Mailing Address - Phone:262-215-9781
Mailing Address - Fax:
Practice Address - Street 1:6500 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1721
Practice Address - Country:US
Practice Address - Phone:262-215-9781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-02
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT140188225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist