Provider Demographics
NPI:1639397169
Name:STADER, SALLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:STADER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 S FLORIDA AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2183
Mailing Address - Country:US
Mailing Address - Phone:863-247-2626
Mailing Address - Fax:
Practice Address - Street 1:4404 S.FLORIDA AVE.
Practice Address - Street 2:SUITE #3
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2169
Practice Address - Country:US
Practice Address - Phone:863-247-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040657A103T00000X
FLPY5379103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist