Provider Demographics
NPI:1982947693
Name:ALTSTATT, NICOLE (PSY D)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:ALTSTATT
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1907
Mailing Address - Country:US
Mailing Address - Phone:631-988-1900
Mailing Address - Fax:
Practice Address - Street 1:1111 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1907
Practice Address - Country:US
Practice Address - Phone:631-988-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018896103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth