Provider Demographics
NPI:1750422101
Name:STODDARD, CLINTON B (LCSW PHD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:B
Last Name:STODDARD
Suffix:
Gender:M
Credentials:LCSW PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BROOKSITE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-265-0060
Mailing Address - Fax:631-265-0757
Practice Address - Street 1:523 TOWNLINE RD
Practice Address - Street 2:SUITE 9
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788
Practice Address - Country:US
Practice Address - Phone:631-265-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037435104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP2717816OtherOXFORD
NY7401979OtherVALUE OPTIONS
NY7401979OtherVALUE OPTIONS