Provider Demographics
NPI:1417202045
Name:PENG, STEPHANIE ANNE (CAP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ANNE
Last Name:PENG
Suffix:
Gender:F
Credentials:CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 W WATERS AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-1229
Mailing Address - Country:US
Mailing Address - Phone:813-881-1000
Mailing Address - Fax:
Practice Address - Street 1:5501 W WATERS AVE STE 404
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-1229
Practice Address - Country:US
Practice Address - Phone:813-881-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5280101YA0400X
FL8995101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health