Provider Demographics
NPI:1558446245
Name:STOLZ, THEODORA (PHD PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:THEODORA
Middle Name:
Last Name:STOLZ
Suffix:
Gender:F
Credentials:PHD PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 GUYON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306
Mailing Address - Country:US
Mailing Address - Phone:718-980-3780
Mailing Address - Fax:718-987-6113
Practice Address - Street 1:68 GUYON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306
Practice Address - Country:US
Practice Address - Phone:718-980-3780
Practice Address - Fax:718-987-6113
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010825103TC0700X
NJ3222103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01627747Medicaid
NJ0028533Medicaid
NJ0028533Medicaid
NYV70791Medicare UPIN