Basic Information
| Provider Information | |||||||||
| NPI: | 1922596493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAUFFER | ||||||||
| FirstName: | THERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 SEAVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ISLAND PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115582208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166608652 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 W HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115806220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168729698 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2018 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.