Provider Demographics
NPI:1770817876
Name:STICKNEY, DAVID JR (MS, ATC, PES)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:STICKNEY
Suffix:JR
Gender:M
Credentials:MS, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-5105
Mailing Address - Country:US
Mailing Address - Phone:203-345-4816
Mailing Address - Fax:
Practice Address - Street 1:600 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-5105
Practice Address - Country:US
Practice Address - Phone:203-345-4816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART004437174400000X
CT000851174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist