Provider Demographics
NPI:1831310424
Name:STALLWORTH, VANZETTA YVONNE (CASAC)
Entity type:Individual
Prefix:MS
First Name:VANZETTA
Middle Name:YVONNE
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CYPRESS STREET
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798
Mailing Address - Country:US
Mailing Address - Phone:631-920-2464
Mailing Address - Fax:
Practice Address - Street 1:1329 BEACH CHANNEL DRIVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:718-337-6850
Practice Address - Fax:718-868-3782
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12572101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)