Provider Demographics
NPI:1447768551
Name:ERICKSON, STEPHANIE ANN (LMT)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANN
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:337 NANCY DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-4623
Mailing Address - Country:US
Mailing Address - Phone:865-867-4243
Mailing Address - Fax:
Practice Address - Street 1:663 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-4906
Practice Address - Country:US
Practice Address - Phone:865-606-0015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11975225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11975OtherMASSAGE LICENSE