Provider Demographics
NPI:1215244611
Name:RILEY, STACY LYNN (PT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:RILEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3072 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-6214
Mailing Address - Country:US
Mailing Address - Phone:631-462-9595
Mailing Address - Fax:631-462-9613
Practice Address - Street 1:3072 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-6214
Practice Address - Country:US
Practice Address - Phone:631-462-9595
Practice Address - Fax:631-462-9613
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NY032998-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032998-1OtherUNIVERSITY OF NEW YORK