Provider Demographics
NPI:1881650281
Name:PETRICK, STANLEY T (MSPT)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:T
Last Name:PETRICK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201B NORTH CHURCH STREET
Mailing Address - Street 2:SUITE 307
Mailing Address - City:HAZLE TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18202-1453
Mailing Address - Country:US
Mailing Address - Phone:570-455-7108
Mailing Address - Fax:570-455-8835
Practice Address - Street 1:1201B NORTH CHURCH STREET
Practice Address - Street 2:SUITE 307
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-1453
Practice Address - Country:US
Practice Address - Phone:570-455-7108
Practice Address - Fax:570-455-8835
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT011725L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00199564OtherRAILROAD MEDICARE
230232OtherHEALTH AMERICA
PA820635OtherFIRST PRIORITY
1230503OtherFIRST HEALTH
PA50038360OtherCAPITAL BLUE CROSS
PAPE176517OtherBLUE SHIELD
1230503OtherFIRST HEALTH