Provider Demographics
NPI:1932121373
Name:FREDERICO, STEPHEN L (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:L
Last Name:FREDERICO
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 NORTH COUNTRY ROAD
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-246-9000
Mailing Address - Fax:631-689-1359
Practice Address - Street 1:1212 NORTH COUNTRY RD
Practice Address - Street 2:SUITE 4B
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:631-246-9000
Practice Address - Fax:631-689-1359
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO225991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN09971Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID