Provider Demographics
NPI:1144663063
Name:RADICE, STEPHANIE JACQUELINE (LMT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JACQUELINE
Last Name:RADICE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4591 SOUTHWESTERN BLVD
Mailing Address - Street 2:APT C4
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-1946
Mailing Address - Country:US
Mailing Address - Phone:716-698-7284
Mailing Address - Fax:
Practice Address - Street 1:1961 WEHRLE DR
Practice Address - Street 2:SUITE 7
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8460
Practice Address - Country:US
Practice Address - Phone:716-626-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY27 026896225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist