Provider Demographics
NPI:1326316001
Name:BACIAK, STEPHEN J II (DPT)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:BACIAK
Suffix:II
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DRIVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:555-321-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 26233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist