Provider Demographics
NPI:1326319591
Name:PENKALSKYJ, TARAS MYCHAJLO (MT)
Entity Type:Individual
Prefix:MR
First Name:TARAS
Middle Name:MYCHAJLO
Last Name:PENKALSKYJ
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 BUSTLETON AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-1918
Mailing Address - Country:US
Mailing Address - Phone:215-725-2300
Mailing Address - Fax:
Practice Address - Street 1:8400 BUSTLETON AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-1918
Practice Address - Country:US
Practice Address - Phone:215-725-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG001563225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist