Provider Demographics
NPI:1215918453
Name:REVAK, STACEY M (PT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:REVAK
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 1:3335 DARBYSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9232
Mailing Address - Country:US
Mailing Address - Phone:330-793-7234
Mailing Address - Fax:
Practice Address - Street 1:3335 DARBYSHIRE DR
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9232
Practice Address - Country:US
Practice Address - Phone:330-793-7234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00214958OtherMEDICARE RAILROAD
OH2523504Medicaid
OH000000344719OtherANTHEM
OH2523504Medicaid