Basic Information
| Provider Information | |||||||||
| NPI: | 1477865095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HELLEN | ||||||||
| FirstName: | STACIE | ||||||||
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| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 VONDERBURG DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 VONDERBURG DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2010 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT25642 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 222Q00000X | PT25642 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1477865095 | 01 | FL | AMERIGROUP | OTHER | 002739900 | 05 | FL | MEDICAID | Y06TM | 01 | FL | BC/BS OF FLORIDA | OTHER | 004070900 | 05 | FL | MEDICAID |