Provider Demographics
NPI:1164149381
Name:DICK, STEPHANIE A (MSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:A
Last Name:DICK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:A
Other - Last Name:AVILES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2719 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5204
Mailing Address - Country:US
Mailing Address - Phone:631-278-8188
Mailing Address - Fax:
Practice Address - Street 1:496 SMITHTOWN BYP STE 203
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5011
Practice Address - Country:US
Practice Address - Phone:631-371-3825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP114522104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker