Provider Demographics
NPI:1790703973
Name:NASSAR, STEPHEN EDWARD (PSYD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:EDWARD
Last Name:NASSAR
Suffix:
Gender:M
Credentials:PSYD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6228103T00000X
FLSW38021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL134222541OtherTRICARE PROVIDER NUMBER
FL54815OtherBCBS PROVIDER NUMBER
FL54815OtherBCBS PROVIDER NUMBER