Provider Demographics
NPI:1538999867
Name:WADSWORTH, STACY MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MICHELLE
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 GLENHILL DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-3811
Mailing Address - Country:US
Mailing Address - Phone:985-860-9693
Mailing Address - Fax:
Practice Address - Street 1:991 GRAND CAILLOU RD BLDG 2
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-5705
Practice Address - Country:US
Practice Address - Phone:985-860-9693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA6837225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist