Provider Demographics
NPI:1740976471
Name:BREWER, STACY (LMBT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5127 REDMON RD
Mailing Address - Street 2:
Mailing Address - City:ELM CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27822-8247
Mailing Address - Country:US
Mailing Address - Phone:919-709-5785
Mailing Address - Fax:
Practice Address - Street 1:3715 AIRPORT BLVD NW STE F
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-7389
Practice Address - Country:US
Practice Address - Phone:919-709-5785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20431225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist