Healthcare Provider Details

I. General information

NPI: 1700858230
Provider Name (Legal Business Name): STEPHEN ATCAVAGE MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 MAIN ST
FOREST CITY PA
18421-1418
US

IV. Provider business mailing address

97 BEECH GROVE RD
HONESDALE PA
18431-4164
US

V. Phone/Fax

Practice location:
  • Phone: 570-785-2018
  • Fax: 570-785-2061
Mailing address:
  • Phone: 570-253-5615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT008367L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: