Provider Demographics
NPI:1093355364
Name:BERUBE, STEPHANIE (LA C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BERUBE
Suffix:
Gender:F
Credentials:LA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 JERUSALEM AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-2017
Mailing Address - Country:US
Mailing Address - Phone:516-499-4925
Mailing Address - Fax:516-781-1184
Practice Address - Street 1:54 HUNNEWELL AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-2707
Practice Address - Country:US
Practice Address - Phone:516-328-7672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006497171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist