Healthcare Provider Details

I. General information

NPI: 1376893701
Provider Name (Legal Business Name): STACI L FAENZA-SEWARD MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 FLORIDA CENTRAL PKWY STE 1028
LONGWOOD FL
32750-7652
US

IV. Provider business mailing address

740 FLORIDA CENTRAL PKWY STE 1028
LONGWOOD FL
32750-7652
US

V. Phone/Fax

Practice location:
  • Phone: 407-774-2284
  • Fax: 407-774-2285
Mailing address:
  • Phone: 407-774-2284
  • Fax: 407-774-2285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH10154
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: