Basic Information
| Provider Information | |||||||||
| NPI: | 1285790709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENGST | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEEHAN | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY STE 307 | ||||||||
| Address2: | |||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BOWMAN DR STE E104 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080439623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562820337 | ||||||||
| FaxNumber: | 8568092142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA00773300 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2412770000 | 01 | NJ | AMERIHEALTH | OTHER | 3637222000 | 01 | NJ | DEPT. OF LABOR | OTHER |