Provider Demographics
NPI:1265905566
Name:STACKPOOLE, THOMAS DAVID (PT)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DAVID
Last Name:STACKPOOLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6525 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3006
Mailing Address - Country:US
Mailing Address - Phone:313-972-4166
Mailing Address - Fax:313-972-4134
Practice Address - Street 1:6525 2ND AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3006
Practice Address - Country:US
Practice Address - Phone:313-972-4140
Practice Address - Fax:313-972-4134
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501010246OtherLARA