Healthcare Provider Details

I. General information

NPI: 1205248606
Provider Name (Legal Business Name): STEFANIE FOREST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST PH 15 WEST 1574
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST PH 15 WEST 1574
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-5697
  • Fax: 212-305-6595
Mailing address:
  • Phone: 212-305-5697
  • Fax: 212-305-6595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: