Provider Demographics
NPI:1194708362
Name:PLUMB, STEPHEN WILLIAM (LISW, LICSW, BCD)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:WILLIAM
Last Name:PLUMB
Suffix:
Gender:M
Credentials:LISW, LICSW, BCD
Other - Prefix:MR
Other - First Name:STEPHEN
Other - Middle Name:W
Other - Last Name:PLUMB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW, BCD
Mailing Address - Street 1:360 BRAINARD ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4004
Mailing Address - Country:US
Mailing Address - Phone:315-785-3600
Mailing Address - Fax:315-785-3600
Practice Address - Street 1:11050 MT BELVEDERE BLVD
Practice Address - Street 2:USA MEDDAC/CREDENTIALS
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00090911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN