Provider Demographics
NPI:1316457393
Name:STACK, CHRISTOPHER THOMAS (DPT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:THOMAS
Last Name:STACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:435 HARTFORD TPKE STE U
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4834
Mailing Address - Country:US
Mailing Address - Phone:860-979-1611
Mailing Address - Fax:860-263-0986
Practice Address - Street 1:489 WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-5709
Practice Address - Country:US
Practice Address - Phone:774-696-8309
Practice Address - Fax:508-297-8416
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MA636162225100000X
MA23576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist