Provider Demographics
NPI:1205071917
Name:STAYTON, ANDREA (MS, BCBA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:STAYTON
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SOL CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8493
Mailing Address - Country:US
Mailing Address - Phone:904-307-3318
Mailing Address - Fax:
Practice Address - Street 1:23 SOL CT
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8493
Practice Address - Country:US
Practice Address - Phone:904-307-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-07-3966103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst