Provider Demographics
NPI:1386217065
Name:ITALIANO, STACEY (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ITALIANO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2203
Mailing Address - Country:US
Mailing Address - Phone:613-521-5137
Mailing Address - Fax:
Practice Address - Street 1:1 GLEN WAY
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2203
Practice Address - Country:US
Practice Address - Phone:613-521-5137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047174225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist