Provider Demographics
NPI:1659305571
Name:STEPHEN E NASSAR PSY D LCSW P A
Entity Type:Organization
Organization Name:STEPHEN E NASSAR PSY D LCSW P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NASSAR
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LCSW
Authorized Official - Phone:321-751-3636
Mailing Address - Street 1:3684 N WICKHAM RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2328
Mailing Address - Country:US
Mailing Address - Phone:321-751-3636
Mailing Address - Fax:321-751-8108
Practice Address - Street 1:3684 N WICKHAM RD
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2328
Practice Address - Country:US
Practice Address - Phone:321-751-3636
Practice Address - Fax:321-751-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6228103T00000X
FLSW38021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4238Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER