Healthcare Provider Details

I. General information

NPI: 1982666822
Provider Name (Legal Business Name): STILLWATER PSYCHOLOGICAL AND OCCUPATIONAL THERAPY ASSOC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 06/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 UNION BLVD
BAY SHORE NY
11706-7932
US

IV. Provider business mailing address

1840 UNION BLVD
BAY SHORE NY
11706-7932
US

V. Phone/Fax

Practice location:
  • Phone: 631-647-7885
  • Fax: 631-647-7893
Mailing address:
  • Phone: 631-647-7885
  • Fax: 631-647-7893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number011241
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number025669
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number009040
License Number StateNY

VIII. Authorized Official

Name: SHAFER ZYZMAN
Title or Position: CEO
Credential:
Phone: 631-647-7885