Healthcare Provider Details

I. General information

NPI: 1538728696
Provider Name (Legal Business Name): BENJAMIN STUCKEY PT, DPT, COTA, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 KINGSBOROUGH SQ STE B
CHESAPEAKE VA
23320-4988
US

IV. Provider business mailing address

PO BOX 412307
BOSTON MA
02241-2307
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-0434
  • Fax: 757-547-0625
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16245-24
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP030726T
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP21981
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: