Provider Demographics
NPI:1770115990
Name:STEPHENS, SHADAEN KRISTAN (BEHAVIOR TECHNICIAN)
Entity type:Individual
Prefix:MS
First Name:SHADAEN
Middle Name:KRISTAN
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6351 N UNIVERSITY DR APT 312
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-4009
Mailing Address - Country:US
Mailing Address - Phone:786-229-5974
Mailing Address - Fax:
Practice Address - Street 1:2615 FAIRWAYS DR
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33035-1173
Practice Address - Country:US
Practice Address - Phone:786-972-4700
Practice Address - Fax:305-508-6697
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-83014106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician