Provider Demographics
NPI:1396482923
Name:CARROLL, STEFFANIE DIANA
Entity type:Individual
Prefix:
First Name:STEFFANIE
Middle Name:DIANA
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 7TH ST STE 3
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2190
Mailing Address - Country:US
Mailing Address - Phone:352-321-9100
Mailing Address - Fax:352-404-8915
Practice Address - Street 1:835 7TH ST STE 3
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2190
Practice Address - Country:US
Practice Address - Phone:352-321-9100
Practice Address - Fax:352-404-8915
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician