Basic Information
Provider Information | |||||||||
NPI: | 1730288028 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUTTON | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | SALYN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DUTTON | ||||||||
OtherFirstName: | STEPHANIE | ||||||||
OtherMiddleName: | SALYN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 340 MAGNOLIA CIR BLDG 1465 | ||||||||
Address2: |   | ||||||||
City: | TYNDALL AFB | ||||||||
State: | FL | ||||||||
PostalCode: | 324035604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502837511 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 340 MAGNOLIA CIR BLDG 1465 | ||||||||
Address2: |   | ||||||||
City: | TYNDALL AFB | ||||||||
State: | FL | ||||||||
PostalCode: | 324035604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502837511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X |   |   | Y |   | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.