Provider Demographics
NPI:1780160887
Name:BOSTON, STEPHANIE (LMT/CMMP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BOSTON
Suffix:
Gender:F
Credentials:LMT/CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 135
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-0135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2518
Practice Address - Country:US
Practice Address - Phone:732-548-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00462000225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist