Provider Demographics
NPI:1528507720
Name:EBENSTEIN, STACY BETH
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:BETH
Last Name:EBENSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FIFTH AVENUE
Mailing Address - Street 2:APT. 22
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:917-816-5199
Mailing Address - Fax:
Practice Address - Street 1:2 5TH AVE
Practice Address - Street 2:APT. 22
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8856
Practice Address - Country:US
Practice Address - Phone:917-816-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0996551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY099655OtherMASTER SOCIAL WORKER LICENSE
NY9597290OtherREGISTRATION CERTIFICATE OFFICE OF THE PROFESSIONS