Provider Demographics
NPI:1538905294
Name:DEMOLE, STEPHANIE (MSTOM LAC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DEMOLE
Suffix:
Gender:F
Credentials:MSTOM LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 MOOSEHORN RD
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06783-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 KIRBY RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06793
Practice Address - Country:US
Practice Address - Phone:732-330-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000808171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist