Provider Demographics
NPI:1164591491
Name:STEPHAN, LINDA BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:BETH
Last Name:STEPHAN
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 1:190 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856-1127
Mailing Address - Country:US
Mailing Address - Phone:607-865-4783
Mailing Address - Fax:
Practice Address - Street 1:190 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856-1127
Practice Address - Country:US
Practice Address - Phone:607-865-4783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007861103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV94351Medicare ID - Type UnspecifiedPSYCHOLOGIST