Healthcare Provider Details

I. General information

NPI: 1033834882
Provider Name (Legal Business Name): DEEANN STALVEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MT BELVEDERE BLVD
FORT DRUM NY
13602-2603
US

IV. Provider business mailing address

11570 MAPLE VIEW PL # B
FORT DRUM NY
13603-3504
US

V. Phone/Fax

Practice location:
  • Phone: 701-367-0584
  • Fax:
Mailing address:
  • Phone: 701-367-0584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810008375
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: