Provider Demographics
NPI:1205035789
Name:MACK, STACY (PTA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 EXECUTIVE PKWY
Mailing Address - Street 2:SUITE 128
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11000 STATE ROUTE 347
Practice Address - Street 2:
Practice Address - City:EAST LIBERTY
Practice Address - State:OH
Practice Address - Zip Code:43319-9470
Practice Address - Country:US
Practice Address - Phone:937-578-0598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 05127225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant