Provider Demographics
NPI:1467953695
Name:STONE, EDEN
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:STONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BLACK JACK CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6751
Mailing Address - Country:US
Mailing Address - Phone:352-332-8588
Mailing Address - Fax:
Practice Address - Street 1:1200 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4450
Practice Address - Country:US
Practice Address - Phone:407-925-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSMedicaid