Provider Demographics
NPI:1144290941
Name:KOSCHERAK, STEPHEN A (PHD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:KOSCHERAK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WAYMAN LN
Mailing Address - Street 2:
Mailing Address - City:BAR HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04609-1625
Mailing Address - Country:US
Mailing Address - Phone:207-288-5081
Mailing Address - Fax:207-288-8600
Practice Address - Street 1:16 COMMUNITY LN
Practice Address - Street 2:
Practice Address - City:SOUTHWEST HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04679-4273
Practice Address - Country:US
Practice Address - Phone:207-244-5630
Practice Address - Fax:207-244-4418
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0042341103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1790764512-009Medicaid
ME1790764512-009Medicaid
R55093Medicare UPIN