Provider Demographics
NPI:1053734137
Name:TEETER, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TEETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7540 187TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98579-9238
Mailing Address - Country:US
Mailing Address - Phone:360-581-5537
Mailing Address - Fax:
Practice Address - Street 1:4804 LACEY BLVD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5733
Practice Address - Country:US
Practice Address - Phone:360-561-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60318995225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist