Provider Demographics
NPI:1376754846
Name:COHEN-MEISSNER, STACEY (PHD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:COHEN-MEISSNER
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:PO BOX 4071
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-4071
Mailing Address - Country:US
Mailing Address - Phone:732-576-1500
Mailing Address - Fax:732-576-1542
Practice Address - Street 1:1221 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-3301
Practice Address - Country:US
Practice Address - Phone:732-576-1500
Practice Address - Fax:732-576-1542
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012780103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01703864Medicaid
NY01703864Medicaid
G400042203Medicare PIN