Provider Demographics
NPI:1598242976
Name:PACHUCHO, ESTEPHANIE J
Entity Type:Individual
Prefix:
First Name:ESTEPHANIE
Middle Name:J
Last Name:PACHUCHO
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 1:6120 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3577
Mailing Address - Country:US
Mailing Address - Phone:718-672-1705
Mailing Address - Fax:
Practice Address - Street 1:6120 WOODSIDE AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3577
Practice Address - Country:US
Practice Address - Phone:718-672-1705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111030-01104100000X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool