Provider Demographics
NPI:1477190379
Name:REID, STACEY LYNN (BT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:REID
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6553
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33807-6553
Mailing Address - Country:US
Mailing Address - Phone:863-602-0698
Mailing Address - Fax:813-354-2715
Practice Address - Street 1:10150 HIGHLAND MANOR DR STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-9712
Practice Address - Country:US
Practice Address - Phone:863-602-0698
Practice Address - Fax:813-354-2715
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician