Provider Demographics
NPI:1033887716
Name:NATHAN-VIRGA, STACEY (PHD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:NATHAN-VIRGA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MAIN STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:MT. KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549
Mailing Address - Country:US
Mailing Address - Phone:914-954-3132
Mailing Address - Fax:
Practice Address - Street 1:153 MAIN STREET
Practice Address - Street 2:SUITE C
Practice Address - City:MT. KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549
Practice Address - Country:US
Practice Address - Phone:914-242-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012204-01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical