Healthcare Provider Details

I. General information

NPI: 1780672154
Provider Name (Legal Business Name): STEPHEN DIAMOND LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 PIKE ST
PORT JERVIS NY
12771-1808
US

IV. Provider business mailing address

146 PIKE ST
PORT JERVIS NY
12771-1808
US

V. Phone/Fax

Practice location:
  • Phone: 845-858-1456
  • Fax: 845-858-1459
Mailing address:
  • Phone: 845-858-1456
  • Fax: 845-858-1459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberR0178051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: