MEDICARE: STEPHANIE K HABECKER MS, LAT, CSCS, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	002419-1	NY

General Provider Information

NPI Number	:	1073934246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE K HABECKER MS, LAT, CSCS, ATC

Provider Business Mailing Address
First Line	:	300 PULTENEY STREET
Second Line	:	BRISTOL GYM
City	:	GENEVA
State	:	NY
Zip	:	14456
Country	:	US
Telephone Number	:	315-781-3568
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 ROUTE 31
Second Line	:	SUITE 12
City	:	MACEDON
State	:	NY
Zip	:	14502-8943
Country	:	US
Telephone Number	:	315-986-4655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2013
Last Update Date	:	03/04/2021

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