Provider Demographics
NPI:1477851780
Name:GOAR, STEPHANIE L (ITDS)
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:L
Last Name:GOAR
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 W BUSCH BLVD
Mailing Address - Street 2:SUITE 916
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-4523
Mailing Address - Country:US
Mailing Address - Phone:813-748-1386
Mailing Address - Fax:
Practice Address - Street 1:2901 W BUSCH BLVD
Practice Address - Street 2:SUITE 916
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4523
Practice Address - Country:US
Practice Address - Phone:813-748-1386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist