Provider Demographics
NPI:1649900473
Name:DISEN, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DISEN
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 1:10311 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-3111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10311 95TH ST
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-3111
Practice Address - Country:US
Practice Address - Phone:631-576-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker