Basic Information
| Provider Information | |||||||||
| NPI: | 1780037002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STETTINIUS | ||||||||
| FirstName: | SHELLEY | ||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 452 LAKE DAISY DRIVE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632890824 | ||||||||
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| Practice Location | |||||||||
| Address1: | 145 EAST EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636192809 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2016 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-16-7022 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.