Provider Demographics
NPI:1477501641
Name:STEPHENS, BETTY
Entity type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:
Last Name:STEPHENS
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 1:2988 MAJESTIC ISLE DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8846
Mailing Address - Country:US
Mailing Address - Phone:352-432-3262
Mailing Address - Fax:352-241-2099
Practice Address - Street 1:2988 MAJESTIC ISLE DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5271
Practice Address - Country:US
Practice Address - Phone:321-948-5355
Practice Address - Fax:352-421-2099
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684984996Medicaid
FL684984998Medicaid