Provider Demographics
NPI:1861690430
Name:STACHURSKI, BRENDA A (DPT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:A
Last Name:STACHURSKI
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 1:12 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1815
Mailing Address - Country:US
Mailing Address - Phone:570-474-5190
Mailing Address - Fax:
Practice Address - Street 1:1000 W 27TH ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-9604
Practice Address - Country:US
Practice Address - Phone:570-454-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist