Provider Demographics
NPI:1750842027
Name:COLLINS, STACY KEY (RBT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:KEY
Last Name:COLLINS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2763 SANDRIDGE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RIDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32442-4359
Mailing Address - Country:US
Mailing Address - Phone:850-593-0078
Mailing Address - Fax:
Practice Address - Street 1:2763 SANDRIDGE CHURCH RD
Practice Address - Street 2:
Practice Address - City:GRAND RIDGE
Practice Address - State:FL
Practice Address - Zip Code:32442-4359
Practice Address - Country:US
Practice Address - Phone:850-593-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-78184106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician