Provider Demographics
NPI:1871753228
Name:DERSHAM, STACEY ANNE (DC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANNE
Last Name:DERSHAM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 BRALEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02770-1917
Mailing Address - Country:US
Mailing Address - Phone:508-725-8307
Mailing Address - Fax:
Practice Address - Street 1:657 PLEASANT ST
Practice Address - Street 2:BOX #5
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-4323
Practice Address - Country:US
Practice Address - Phone:508-677-2554
Practice Address - Fax:508-677-2553
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT001788111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program