Provider Demographics
NPI:1528572690
Name:ZGALJARDIC, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ZGALJARDIC
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 1:5407 BROWVALE LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1701
Mailing Address - Country:US
Mailing Address - Phone:646-267-8111
Mailing Address - Fax:
Practice Address - Street 1:1 EXPRESSWAY PLZ STE 106
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2069
Practice Address - Country:US
Practice Address - Phone:516-621-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool