Healthcare Provider Details

I. General information

NPI: 1912951484
Provider Name (Legal Business Name): STEPHAN K KOBLICK MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 FLATBUSH AVENUE EXT
BROOKLYN NY
11201-1906
US

IV. Provider business mailing address

71 BEAUMONT ST
BROOKLYN NY
11235-4103
US

V. Phone/Fax

Practice location:
  • Phone: 718-439-4337
  • Fax: 718-439-4340
Mailing address:
  • Phone: 718-439-4337
  • Fax: 718-439-4340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPRO15480-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: