Provider Demographics
NPI:1134004351
Name:SMALL, STACEY (LMBT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 FOUNDRY DR APT 4119
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3813
Mailing Address - Country:US
Mailing Address - Phone:617-412-1554
Mailing Address - Fax:
Practice Address - Street 1:4523 PARK RD # A102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3700
Practice Address - Country:US
Practice Address - Phone:704-919-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21718225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist