Provider Demographics
NPI:1285790709
Name:HENGST, STACEY (MPT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HENGST
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:SHEEHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:200 BOWMAN DR STE E104
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9623
Practice Address - Country:US
Practice Address - Phone:856-282-0337
Practice Address - Fax:856-809-2142
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00773300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2412770000OtherAMERIHEALTH
NJ3637222000OtherDEPT. OF LABOR
NJ090974R5AMedicare ID - Type UnspecifiedMEDICARE