Provider Demographics
NPI:1104908029
Name:WENTWORTH, STACY LYNN (PT)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:DEFAZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:38 RIDGE MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559
Mailing Address - Country:US
Mailing Address - Phone:585-349-1455
Mailing Address - Fax:
Practice Address - Street 1:3 WEST AVE
Practice Address - Street 2:
Practice Address - City:LEROY
Practice Address - State:NY
Practice Address - Zip Code:14482
Practice Address - Country:US
Practice Address - Phone:585-768-4550
Practice Address - Fax:585-768-2335
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0229541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD4434Medicare ID - Type Unspecified