Healthcare Provider Details

I. General information

NPI: 1659305571
Provider Name (Legal Business Name): STEPHEN E NASSAR PSY D LCSW P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3684 N WICKHAM RD SUITE B
MELBOURNE FL
32935-2328
US

IV. Provider business mailing address

3684 N WICKHAM RD SUITE B
MELBOURNE FL
32935-2328
US

V. Phone/Fax

Practice location:
  • Phone: 321-751-3636
  • Fax: 321-751-8108
Mailing address:
  • Phone: 321-751-3636
  • Fax: 321-751-8108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6228
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW3802
License Number StateFL

VIII. Authorized Official

Name: DR. STEPHEN EDWARD NASSAR
Title or Position: CEO
Credential: PSYD, LCSW
Phone: 321-751-3636