MEDICARE: SIOBHAN CATHERINE STACK DPT

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	2251X0800X	Orthopedic Physical Therapist	049448	NY

General Provider Information

NPI Number	:	1366145054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIOBHAN CATHERINE STACK DPT

Provider Business Mailing Address
First Line	:	62 W MAIN ST
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8314
Country	:	US
Telephone Number	:	516-830-1818
Fax Number	:

Provider Business Practice Location Address
First Line	:	62 W MAIN ST
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8314
Country	:	US
Telephone Number	:	631-665-4560
Fax Number	:

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

Provider Enumeration Date	:	03/23/2023
Last Update Date	:	03/23/2023

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