Basic Information
Provider Information | |||||||||
NPI: | 1265534655 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NEUSTADTER | ||||||||
FirstName: | STEFAN | ||||||||
MiddleName: | SHEPARD | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRANCA | ||||||||
OtherFirstName: | DONNA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: | SR. | ||||||||
OtherCredential: | MSW | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 279 HAMILTON PLACE | ||||||||
Address2: |   | ||||||||
City: | HACKENSACK | ||||||||
State: | NJ | ||||||||
PostalCode: | 07601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 151 KNOLLCROFT ROAD | ||||||||
Address2: |   | ||||||||
City: | LYONS | ||||||||
State: | NJ | ||||||||
PostalCode: | 07939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9086470180 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 44SC00757600 | NJ | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.