Provider Demographics
NPI:1629347141
Name:STANLEY J PALUMBO
Entity Type:Organization
Organization Name:STANLEY J PALUMBO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALUMBO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:330-744-1027
Mailing Address - Street 1:1350 5TH AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1728
Mailing Address - Country:US
Mailing Address - Phone:330-744-1027
Mailing Address - Fax:330-744-1029
Practice Address - Street 1:1350 5TH AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1728
Practice Address - Country:US
Practice Address - Phone:330-744-1027
Practice Address - Fax:330-744-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1964103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0353175Medicaid
OHPENDINGMedicare PIN