Provider Demographics
NPI:1871938852
Name:STOCK, CARLY (PT)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:STOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:MATICHAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2314 PULASKI HWY
Practice Address - Street 2:SUITE A
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-3730
Practice Address - Country:US
Practice Address - Phone:410-287-2940
Practice Address - Fax:410-287-2941
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23227225100000X
PA020439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist