Provider Demographics
NPI:1417101585
Name:LONGO, STEPHANIE MARIE (BCBA, LMSW, ITDS)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:LONGO
Suffix:
Gender:F
Credentials:BCBA, LMSW, ITDS
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:FUSCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, BCBA, ITDS
Mailing Address - Street 1:350 FAIRWAY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1834
Mailing Address - Country:US
Mailing Address - Phone:877-418-2978
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:350 FAIRWAY DR STE 101
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1834
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-15
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X, 222Q00000X, 106E00000X
FL1-20-45233103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022921500Medicaid