Basic Information
Provider Information | |||||||||
NPI: | 1831310424 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STALLWORTH | ||||||||
FirstName: | VANZETTA | ||||||||
MiddleName: | YVONNE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CASAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 35 CYPRESS STREET | ||||||||
Address2: |   | ||||||||
City: | WYANDANCH | ||||||||
State: | NY | ||||||||
PostalCode: | 11798 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6319202464 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1329 BEACH CHANNEL DRIVE | ||||||||
Address2: |   | ||||||||
City: | FAR ROCKAWAY | ||||||||
State: | NY | ||||||||
PostalCode: | 11691 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7183376850 | ||||||||
FaxNumber: | 7188683782 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 12572 | NY | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.