Provider Demographics
NPI:1548530223
Name:CHAN, STEPHANIE LYNN (CMT, NCTMB)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:CHAN
Suffix:
Gender:F
Credentials:CMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14998 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-8992
Mailing Address - Country:US
Mailing Address - Phone:231-730-2769
Mailing Address - Fax:
Practice Address - Street 1:14998 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-8992
Practice Address - Country:US
Practice Address - Phone:231-730-2769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist