Provider Demographics
NPI:1649687260
Name:STACK, SARAH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 BLACK BEAR RUN
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:OH
Mailing Address - Zip Code:44050-8808
Mailing Address - Country:US
Mailing Address - Phone:440-452-6869
Mailing Address - Fax:
Practice Address - Street 1:709 BLACK BEAR RUN
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:OH
Practice Address - Zip Code:44050
Practice Address - Country:US
Practice Address - Phone:440-452-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05558225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant