Provider Demographics
NPI:1922596493
Name:STAUFFER, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:STAUFFER
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 1:5 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ISLAND PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11558-2208
Mailing Address - Country:US
Mailing Address - Phone:516-660-8652
Mailing Address - Fax:
Practice Address - Street 1:50 W HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6220
Practice Address - Country:US
Practice Address - Phone:516-872-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker