=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942590617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MARK STAUM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2011
-----------------------------------------------------
Last Update Date | 08/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 441 ROUTE 306 2ND FLOOR-SUITE 3
-----------------------------------------------------
City | MONSEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10952-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-952-4436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 441 ROUTE 306 2ND FLOOR-SUITE 3
-----------------------------------------------------
City | MONSEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10952-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-952-4436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 73 078451
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 72 065504
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------