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NPI Code Detail

MEDICARE: STEPHEN MARK PEDERSON

MEDICARE: STEPHEN MARK PEDERSON
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
1106S00000XBehavior Technician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1821575143
Entity Type Code : Individual
Provider Name (Legal Business Name) : STEPHEN MARK PEDERSON
Provider Business Mailing Address
First Line : 1393 BELVEDERE AVE
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32205-7942
Country : US
Telephone Number : 612-250-7503
Fax Number :
Provider Business Practice Location Address
First Line : 13553 ATLANTIC BLVD STE 100
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32225-4227
Country : US
Telephone Number : 904-420-7030
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2018
Last Update Date : 03/04/2021

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