Individual
MS. STACEY L ANDERSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LAC WI#803-55/ LMT W
Contact information
Practice address
5603 7TH AVE, KENOSHA, WI 53140
(262) 496-5642
Mailing address
8607 OLD GREEN BAY RD, KENOSHA, WI 53158
(262) 496-5642
Taxonomy
Speciality
Code
Description
License number
State
171100000X
Acupuncturist
Primary
803-55
WI
225700000X
Massage Therapist
4199-146
WI
Other
Enumeration date
10/01/2013
Last updated
10/01/2013
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