Provider Demographics
NPI:1780410738
Name:STOCKER, ITAMARA
Entity type:Individual
Prefix:
First Name:ITAMARA
Middle Name:
Last Name:STOCKER
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 1:435 DEAN CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-8109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8257 NARCOOSSEE PARK DRIVE BUILDING #1
Practice Address - Street 2:UNIT #508C
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822
Practice Address - Country:US
Practice Address - Phone:321-701-3064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH24235101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health