Provider Demographics
NPI:1467762708
Name:STAUBER, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:STAUBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 RIVERSIDE DR
Mailing Address - Street 2:SUITE 730
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10115-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 RIVERSIDE DR
Practice Address - Street 2:SUITE 730
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10115-0002
Practice Address - Country:US
Practice Address - Phone:212-280-4473
Practice Address - Fax:212-280-5384
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool