Provider Demographics
NPI:1003778382
Name:PARK, STACY E (LMT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:E
Last Name:PARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:E
Other - Last Name:SANDLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2923 JACKSON HWY
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-8650
Mailing Address - Country:US
Mailing Address - Phone:360-996-4778
Mailing Address - Fax:360-996-4783
Practice Address - Street 1:2923 JACKSON HWY STE B
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-8650
Practice Address - Country:US
Practice Address - Phone:360-996-4778
Practice Address - Fax:360-996-4783
Is Sole Proprietor?:No
Enumeration Date:2025-11-25
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA70066055225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist