Provider Demographics
NPI:1780241810
Name:STACEY, GENEVA (MMT)
Entity type:Individual
Prefix:
First Name:GENEVA
Middle Name:
Last Name:STACEY
Suffix:
Gender:F
Credentials:MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 W KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4234
Mailing Address - Country:US
Mailing Address - Phone:870-239-0368
Mailing Address - Fax:
Practice Address - Street 1:521 W KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4234
Practice Address - Country:US
Practice Address - Phone:870-239-0368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2591225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty