Provider Demographics
NPI:1588386874
Name:STACK JEW, CHELSEA (PSYD)
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:STACK JEW
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 LYDIA DR
Mailing Address - Street 2:
Mailing Address - City:GUTTENBERG
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-8301
Mailing Address - Country:US
Mailing Address - Phone:909-455-4551
Mailing Address - Fax:
Practice Address - Street 1:7901 BROADWAY OFC 11-113
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP116700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical