Provider Demographics
NPI:1699935866
Name:LACK, CAROLYN REBECCA (DPT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:REBECCA
Last Name:LACK
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 1:50 LEXINGTON AVE
Mailing Address - Street 2:APT 24A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-2935
Mailing Address - Country:US
Mailing Address - Phone:212-674-3231
Mailing Address - Fax:
Practice Address - Street 1:147 W 24TH ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-1911
Practice Address - Country:US
Practice Address - Phone:212-997-7490
Practice Address - Fax:212-997-7492
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025886-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist