Basic Information
| Provider Information | |||||||||
| NPI: | 1952741845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISH | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PMHNP-BC, MSN, ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 EAST SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219526000 | ||||||||
| FaxNumber: | 3219526010 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217225200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2013 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN2925952 | FL | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.