Provider Demographics
NPI:1952522930
Name:HASSEN STACK, KATHLEEN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:HASSEN STACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GLEN ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06471-1263
Mailing Address - Country:US
Mailing Address - Phone:203-415-9072
Mailing Address - Fax:203-937-1064
Practice Address - Street 1:4 GLEN ROAD
Practice Address - Street 2:
Practice Address - City:NORTH BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06471-1263
Practice Address - Country:US
Practice Address - Phone:203-415-9072
Practice Address - Fax:203-937-1064
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT005200OtherPT LICENSE NUMBER
CT080005200CT01OtherANTHEM PROVIDER NUMBER
CT11340795OtherCAQH PROVIDER ID