Provider Demographics
NPI:1912615774
Name:OSUBA, STEPHANIE (LAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:OSUBA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BAYARD ST FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-2392
Mailing Address - Country:US
Mailing Address - Phone:732-847-2869
Mailing Address - Fax:
Practice Address - Street 1:104 BAYARD ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2392
Practice Address - Country:US
Practice Address - Phone:732-847-2869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00676400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health