Provider Demographics
NPI:1538144936
Name:STOLZBERG, MARK ELLIOTT (PHD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELLIOTT
Last Name:STOLZBERG
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6759 SHAMROCK TRL
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-3913
Mailing Address - Country:US
Mailing Address - Phone:631-751-4277
Mailing Address - Fax:
Practice Address - Street 1:6759 SHAMROCK TRL
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3913
Practice Address - Country:US
Practice Address - Phone:631-751-4277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010826103TC0700X
FLPY 7740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL851Medicare PIN
NYV73281Medicare ID - Type Unspecified
FLAL851Medicare PIN