Healthcare Provider Details

I. General information

NPI: 1982947693
Provider Name (Legal Business Name): NICOLE ALTSTATT PSY. D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 ROUTE 25A
STONY BROOK NY
11790-1907
US

IV. Provider business mailing address

1111 ROUTE 25A
STONY BROOK NY
11790-1907
US

V. Phone/Fax

Practice location:
  • Phone: 631-988-1900
  • Fax:
Mailing address:
  • Phone: 631-988-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number018896
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: