Provider Demographics
NPI:1366628521
Name:PROSOWSKI, STACY (STACY PROSOWSKI)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PROSOWSKI
Suffix:
Gender:F
Credentials:STACY PROSOWSKI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 PARK DR
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 PARK DR
Practice Address - Street 2:#22
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4744
Practice Address - Country:US
Practice Address - Phone:555-555-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist