Provider Demographics
NPI:1710527163
Name:MENDEZ, STACIE A
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:A
Last Name:MENDEZ
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 1:8001 SW 36TH ST STE 9
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1915
Mailing Address - Country:US
Mailing Address - Phone:954-577-7790
Mailing Address - Fax:954-577-7780
Practice Address - Street 1:150 E ROBINSON ST UNIT 2512
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-4361
Practice Address - Country:US
Practice Address - Phone:407-782-6914
Practice Address - Fax:954-577-7780
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLMH23188101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician