Provider Demographics
NPI:1629387501
Name:VARGAS, STACEY LYNN (BCABA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:VARGAS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SW SOUTH WAKEFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5446
Mailing Address - Country:US
Mailing Address - Phone:954-297-8534
Mailing Address - Fax:
Practice Address - Street 1:900 SE OCEAN BLVD STE 130D
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3503
Practice Address - Country:US
Practice Address - Phone:954-297-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-04-1259103K00000X
FL0-14-1259106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst