Provider Demographics
NPI:1346989613
Name:DORGELUS, STACEY (RBT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:DORGELUS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2733 SPRINGFIELD DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-8665
Mailing Address - Country:US
Mailing Address - Phone:407-437-9328
Mailing Address - Fax:
Practice Address - Street 1:3200 S HIAWASSEE RD SUITE 203 ROOM 1249
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835
Practice Address - Country:US
Practice Address - Phone:321-972-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-08-10
Deactivation Date:2022-07-09
Deactivation Code:
Reactivation Date:2022-08-09
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-217224106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician