Provider Demographics
NPI:1740980226
Name:STANLEY, IMMARI (LMT)
Entity type:Individual
Prefix:
First Name:IMMARI
Middle Name:
Last Name:STANLEY
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 1:1020 BRADDOCK CIR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-2381
Mailing Address - Country:US
Mailing Address - Phone:517-755-7760
Mailing Address - Fax:
Practice Address - Street 1:1020 BRADDOCK CIR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-2381
Practice Address - Country:US
Practice Address - Phone:517-755-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT014074225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist