Provider Demographics
NPI:1225399967
Name:SANDON, STEPHEN MARK
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MARK
Last Name:SANDON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:STEPHEN
Other - Middle Name:MARK
Other - Last Name:SANDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW , BCBA
Mailing Address - Street 1:4233 MAINSAIL ST
Mailing Address - Street 2:2014 DELTA BLVD.
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7424
Mailing Address - Country:US
Mailing Address - Phone:850-445-4298
Mailing Address - Fax:850-562-0909
Practice Address - Street 1:4233 MAINSAIL ST
Practice Address - Street 2:2014 DELTA BLVD
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-7424
Practice Address - Country:US
Practice Address - Phone:850-445-4298
Practice Address - Fax:850-562-0909
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
FLSW 82161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000131401Medicaid
FL000131400Medicaid