Provider Demographics
NPI:1013148915
Name:STACK, KATHLEEN MARY
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARY
Other - Last Name:MAGUIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 BEACH 92ND ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1509
Mailing Address - Country:US
Mailing Address - Phone:178-547-1039
Mailing Address - Fax:
Practice Address - Street 1:1666 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:718-456-7588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019277-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist