Provider Demographics
NPI:1720608219
Name:STEPHEN DI CERBO LMFT PA
Entity Type:Organization
Organization Name:STEPHEN DI CERBO LMFT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DI CERBO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:321-848-3979
Mailing Address - Street 1:2781 MAJESTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7574
Mailing Address - Country:US
Mailing Address - Phone:321-848-3979
Mailing Address - Fax:
Practice Address - Street 1:2781 MAJESTIC AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7574
Practice Address - Country:US
Practice Address - Phone:321-848-3979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-24
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
12664043OtherCAQH
FL015336400Medicaid
1114260064OtherNPI