Provider Demographics
NPI:1740808880
Name:JANCZAK, STEPHANIE L (LMT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:JANCZAK
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 1:39582 LEGEND CT
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-3936
Mailing Address - Country:US
Mailing Address - Phone:734-718-4165
Mailing Address - Fax:
Practice Address - Street 1:39582 LEGEND CT
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-3936
Practice Address - Country:US
Practice Address - Phone:734-718-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501009404225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist