Provider Demographics
NPI:1437703345
Name:STACK, MARISA D (DPT)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:D
Last Name:STACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:MARISA
Other - Middle Name:D
Other - Last Name:ARELLANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2004 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4930
Mailing Address - Country:US
Mailing Address - Phone:415-583-7052
Mailing Address - Fax:
Practice Address - Street 1:140 WIKIUP DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7756
Practice Address - Country:US
Practice Address - Phone:707-542-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist