Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | OC009176 | PA |
NPI | 1104446178 |
---|---|
Provider Name | Spencer Stack |
First Address | Allentown, PA 18106-8727 |
Second Address | Allentown, PA 18102-3648 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2020 |
Last Update Date | 20/04/2020 |