Provider Demographics
NPI:1790876761
Name:COHEN, STACEY M (MSPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:COHEN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:GOLDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:143 W LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-1001
Mailing Address - Country:US
Mailing Address - Phone:973-476-0816
Mailing Address - Fax:
Practice Address - Street 1:1450 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:212-241-1912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024094225100000X
NJ40QA00987600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist