Provider Demographics
NPI:1841657210
Name:CASTER, STACEY EIDLEBACH (LMT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:EIDLEBACH
Last Name:CASTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MISCHELLE
Other - Last Name:EIDLEBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 W LAS ANIMAS ST
Mailing Address - Street 2:APT 3
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-4164
Mailing Address - Country:US
Mailing Address - Phone:682-472-5054
Mailing Address - Fax:
Practice Address - Street 1:5 W LAS ANIMAS ST
Practice Address - Street 2:APT 3
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4164
Practice Address - Country:US
Practice Address - Phone:682-472-5054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0017786225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist