Provider Demographics
NPI:1770073058
Name:MATOS-TABASHNECK, STEPHANIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:MATOS-TABASHNECK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:TABASHNECK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:240 HEATH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1141
Mailing Address - Country:US
Mailing Address - Phone:248-840-3186
Mailing Address - Fax:
Practice Address - Street 1:240 HEATH ST APT 102
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-1141
Practice Address - Country:US
Practice Address - Phone:248-840-3186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-13
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10142103TC1900X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling