Provider Demographics
NPI:1174981435
Name:STACK, DONNA (PT)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:STACK
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 1:119 PROFESSIONAL CTR
Mailing Address - Street 2:1265 WAYNE AVENUE, SUITE 308
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3586
Mailing Address - Country:US
Mailing Address - Phone:724-801-8095
Mailing Address - Fax:724-801-8147
Practice Address - Street 1:4709 KIRKWOOD HWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5007
Practice Address - Country:US
Practice Address - Phone:302-998-9880
Practice Address - Fax:302-998-7498
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist