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NPI Code Detail

MEDICARE: DR. SALLY STADER PH.D.

MEDICARE: DR. SALLY STADER PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologist20040657AIN
2103T00000XPsychologistPY5379FL

General Provider Information

NPI Number : 1639397169
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SALLY STADER PH.D.
Provider Business Mailing Address
First Line : 4404 S FLORIDA AVE STE 3
Second Line :
City : LAKELAND
State : FL
Zip : 33813-2183
Country : US
Telephone Number : 863-247-2626
Fax Number :
Provider Business Practice Location Address
First Line : 4404 S.FLORIDA AVE.
Second Line : SUITE #3
City : LAKELAND
State : FL
Zip : 33813-2169
Country : US
Telephone Number : 863-247-2626
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/22/2007
Last Update Date : 12/10/2022

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Directions to “ DR. SALLY STADER PH.D.” Practice Location

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