Provider Demographics
NPI:1912081787
Name:THEODORA STOLZ CLINIC
Entity Type:Organization
Organization Name:THEODORA STOLZ CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-980-3780
Mailing Address - Street 1:68 GUYON AVE
Mailing Address - Street 2:
Mailing Address - City:S I
Mailing Address - State:NY
Mailing Address - Zip Code:10306
Mailing Address - Country:US
Mailing Address - Phone:718-980-3780
Mailing Address - Fax:718-987-6113
Practice Address - Street 1:68 GUYON AVE
Practice Address - Street 2:
Practice Address - City:S I
Practice Address - State:NY
Practice Address - Zip Code:10306
Practice Address - Country:US
Practice Address - Phone:718-980-3780
Practice Address - Fax:718-987-6113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010825103TC0700X
NJ3222103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01627747Medicaid
NJ0028533Medicaid
NJ0028533Medicaid
NYV70791Medicare ID - Type Unspecified