Provider Demographics
NPI:1497064786
Name:STACK, MAUREEN
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 WACHUSETTS ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:559 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:EAST ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11518-1530
Practice Address - Country:US
Practice Address - Phone:516-241-3684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015582225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics