Provider Demographics
NPI:1679647572
Name:STACK, DOROTHY (PT)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:
Last Name:STACK
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 1:737 WANTAGH AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11179
Mailing Address - Country:US
Mailing Address - Phone:576-796-8490
Mailing Address - Fax:576-796-8771
Practice Address - Street 1:737 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11179
Practice Address - Country:US
Practice Address - Phone:576-796-8490
Practice Address - Fax:576-796-8771
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0043371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY47197POtherHIP
NY10111850OtherUNITED HEALTH
NY6600490OtherGHI
NY10111850OtherUNITED HEALTH