Provider Demographics
NPI:1942590617
Name:STAUM, MARK
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:STAUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 ROUTE 306
Mailing Address - Street 2:2ND FLOOR-SUITE 3
Mailing Address - City:MONSEY
Mailing Address - State:NY
Mailing Address - Zip Code:10952-1233
Mailing Address - Country:US
Mailing Address - Phone:201-952-4436
Mailing Address - Fax:
Practice Address - Street 1:441 ROUTE 306
Practice Address - Street 2:2ND FLOOR-SUITE 3
Practice Address - City:MONSEY
Practice Address - State:NY
Practice Address - Zip Code:10952-1233
Practice Address - Country:US
Practice Address - Phone:201-952-4436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-14
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73 0784511041C0700X
NY72 0655041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical