Provider Demographics
NPI:1073930418
Name:HANAK, STACY GOLBORO
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:GOLBORO
Last Name:HANAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 ARCH ST 5
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1300
Mailing Address - Country:US
Mailing Address - Phone:267-256-2115
Mailing Address - Fax:
Practice Address - Street 1:191 PRESIDENTIAL BLVD STE C129
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1216
Practice Address - Country:US
Practice Address - Phone:484-334-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0179741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical