Provider Demographics
NPI:1265690366
Name:STALLWORTH COMMUNITY SERVICES INC
Entity Type:Organization
Organization Name:STALLWORTH COMMUNITY SERVICES INC
Other - Org Name:SUCCESSFUL DEVELOPMENT INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:LATRICE
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:941-536-4449
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:TALLEVAST
Mailing Address - State:FL
Mailing Address - Zip Code:34270
Mailing Address - Country:US
Mailing Address - Phone:941-536-4449
Mailing Address - Fax:941-355-8699
Practice Address - Street 1:304 26TH AVENUE EAST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208
Practice Address - Country:US
Practice Address - Phone:941-536-4449
Practice Address - Fax:941-355-8699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690209096Medicaid