Provider Demographics
NPI:1659904951
Name:ANDERSON, STEPHANIE SPAIN (MA, PHD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SPAIN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 N SYKES CREEK PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3494
Mailing Address - Country:US
Mailing Address - Phone:321-323-9069
Mailing Address - Fax:
Practice Address - Street 1:270 N SYKES CREEK PKWY STE 106
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3494
Practice Address - Country:US
Practice Address - Phone:321-323-9069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17177101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health