Provider Demographics
NPI:1477048064
Name:FORMOSO, STEPHANIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:FORMOSO
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 1:126 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-1318
Mailing Address - Country:US
Mailing Address - Phone:516-486-7200
Mailing Address - Fax:
Practice Address - Street 1:1065 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-2417
Practice Address - Country:US
Practice Address - Phone:718-858-9160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109412-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker