Healthcare Provider Details

I. General information

NPI: 1336869122
Provider Name (Legal Business Name): STACIE R MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 US HWY 441 SUITE B3
FRUITLAND PARK FL
34731-4497
US

IV. Provider business mailing address

3261 US HWY 441 SUITE B3
FRUITLAND PARK FL
34731-4497
US

V. Phone/Fax

Practice location:
  • Phone: 352-323-0612
  • Fax: 352-787-2386
Mailing address:
  • Phone: 352-323-0612
  • Fax: 352-787-2386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: