Provider Demographics
NPI:1407158256
Name:WENCK, STACEY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:WENCK
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 1:738 ALDWORTH RD
Mailing Address - Street 2:
Mailing Address - City:DUNDALK
Mailing Address - State:MD
Mailing Address - Zip Code:21222-1304
Mailing Address - Country:US
Mailing Address - Phone:443-503-5307
Mailing Address - Fax:
Practice Address - Street 1:9200 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4458
Practice Address - Country:US
Practice Address - Phone:443-391-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3549225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant