Healthcare Provider Details

I. General information

NPI: 1376280792
Provider Name (Legal Business Name): MATTHEW STEFONETTI PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE
BATH NY
14810-0810
US

IV. Provider business mailing address

1073 SING SING RD APT E5
HORSEHEADS NY
14845-1394
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS019577
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: