Provider Demographics
NPI:1588771547
Name:STUBENHAUS, ERIC C (PHD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:C
Last Name:STUBENHAUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DUNDEE PARK
Mailing Address - Street 2:SUITE B05
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810
Mailing Address - Country:US
Mailing Address - Phone:978-475-6622
Mailing Address - Fax:978-475-8436
Practice Address - Street 1:3 DUNDEE PARK
Practice Address - Street 2:SUITE B05
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810
Practice Address - Country:US
Practice Address - Phone:978-475-6622
Practice Address - Fax:978-475-8436
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47372084P0800X, 103TC2200X, 103T00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0521418Medicaid
MASTW04541Medicare ID - Type Unspecified
MA0521418Medicaid