Provider Demographics
NPI:1376893701
Name:FAENZA-SEWARD, STACI L (MS)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:L
Last Name:FAENZA-SEWARD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 FLORIDA CENTRAL PKWY STE 1028
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-7652
Mailing Address - Country:US
Mailing Address - Phone:407-774-2284
Mailing Address - Fax:407-774-2285
Practice Address - Street 1:740 FLORIDA CENTRAL PKWY STE 1028
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-7652
Practice Address - Country:US
Practice Address - Phone:407-774-2284
Practice Address - Fax:407-774-2285
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IMH10154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health