Provider Demographics
NPI:1366145054
Name:STACK, SIOBHAN CATHERINE (DPT)
Entity type:Individual
Prefix:
First Name:SIOBHAN
Middle Name:CATHERINE
Last Name:STACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8314
Mailing Address - Country:US
Mailing Address - Phone:516-830-1818
Mailing Address - Fax:
Practice Address - Street 1:62 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8314
Practice Address - Country:US
Practice Address - Phone:631-665-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0494482251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic