Individual
MRS. KATHLEEN HASSEN STACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PT
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
005200
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
005200
PT LICENSE NUMBER
CT
01
—
080005200CT01
ANTHEM PROVIDER NUMBER
CT
01
—
11340795
CAQH PROVIDER ID
CT
Enumeration date
05/01/2007
Last updated
07/08/2007
Update your record
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