Healthcare Provider Details

I. General information

NPI: 1760126585
Provider Name (Legal Business Name): STEPHEN JOSEPH EDELSTEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 JOHNSON ST
STATEN ISLAND NY
10309-1148
US

IV. Provider business mailing address

19 2ND ST
STATEN ISLAND NY
10306-2203
US

V. Phone/Fax

Practice location:
  • Phone: 718-979-5678
  • Fax:
Mailing address:
  • Phone: 718-490-4485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number454571
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: