Provider Demographics
NPI:1831716414
Name:STEDMAN, DESTINY LEE
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:LEE
Last Name:STEDMAN
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 1:810 SHONEY DR SW STE 115
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-5450
Mailing Address - Country:US
Mailing Address - Phone:256-905-7627
Mailing Address - Fax:
Practice Address - Street 1:810 SHONEY DR SW STE 115
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5450
Practice Address - Country:US
Practice Address - Phone:256-905-7627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALBACB583360106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician