Provider Demographics
NPI:1851488357
Name:PHELPS, STEPHEN WALTER (PSYD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:WALTER
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GUILDERLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12084
Mailing Address - Country:US
Mailing Address - Phone:518-456-5056
Mailing Address - Fax:518-456-6512
Practice Address - Street 1:2280 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GUILDERLAND
Practice Address - State:NY
Practice Address - Zip Code:12084
Practice Address - Country:US
Practice Address - Phone:518-456-5056
Practice Address - Fax:518-456-6512
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010375-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01700054Medicaid
NY5295SCMedicare ID - Type Unspecified