Provider Demographics
NPI:1750738746
Name:SANTAGATA, STACEY (BCBA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SANTAGATA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:CHEESEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:5 REVERE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8005
Mailing Address - Country:US
Mailing Address - Phone:941-416-4338
Mailing Address - Fax:
Practice Address - Street 1:2565 N TOLEDO BLADE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34289-9306
Practice Address - Country:US
Practice Address - Phone:941-416-4338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-15-21193103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst