Provider Demographics
NPI:1003366576
Name:STAMBOULIS, COSTANTINOS (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:COSTANTINOS
Middle Name:
Last Name:STAMBOULIS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14916 17TH RD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-2542
Mailing Address - Country:US
Mailing Address - Phone:917-662-3041
Mailing Address - Fax:
Practice Address - Street 1:2408 32ND ST STE 1002D
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-1139
Practice Address - Country:US
Practice Address - Phone:718-734-2373
Practice Address - Fax:718-734-2372
Is Sole Proprietor?:No
Enumeration Date:2016-10-09
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020698225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist