Healthcare Provider Details

I. General information

NPI: 1306053285
Provider Name (Legal Business Name): STACY MARIE YEARWOOD M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARSTOW ROAD STE P24
GREAT NECK NY
11021
US

IV. Provider business mailing address

1 BARSTOW ROAD STE P24
GREAT NECK NY
11021
US

V. Phone/Fax

Practice location:
  • Phone: 516-417-4077
  • Fax: 888-608-9321
Mailing address:
  • Phone: 516-417-4077
  • Fax: 888-608-9321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number246269
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number246269
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: