Provider Demographics
NPI:1972673150
Name:STANEK, TERRY L (MSPT)
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:L
Last Name:STANEK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7814 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3536
Mailing Address - Country:US
Mailing Address - Phone:708-456-2322
Mailing Address - Fax:708-456-2395
Practice Address - Street 1:7814 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-3536
Practice Address - Country:US
Practice Address - Phone:708-456-2322
Practice Address - Fax:708-456-2395
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146667Medicare ID - Type Unspecified