Healthcare Provider Details

I. General information

NPI: 1457030850
Provider Name (Legal Business Name): MARISSA GRACE STEVENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 W STATE ROAD 434
LONGWOOD FL
32750-5067
US

IV. Provider business mailing address

1775 W STATE ROAD 434
LONGWOOD FL
32750-5067
US

V. Phone/Fax

Practice location:
  • Phone: 844-244-1818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: