Provider Demographics
NPI:1982666822
Name:STILLWATER PSYCHOLOGICAL AND OCCUPATIONAL THERAPY ASSOC PLLC
Entity Type:Organization
Organization Name:STILLWATER PSYCHOLOGICAL AND OCCUPATIONAL THERAPY ASSOC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZYZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-647-7885
Mailing Address - Street 1:1840 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7932
Mailing Address - Country:US
Mailing Address - Phone:631-647-7885
Mailing Address - Fax:631-647-7893
Practice Address - Street 1:1840 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7932
Practice Address - Country:US
Practice Address - Phone:631-647-7885
Practice Address - Fax:631-647-7893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011241103TC0700X
NY025669104100000X
NY009040225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02678068Medicaid
NY02678068Medicaid