Healthcare Provider Details

I. General information

NPI: 1104720424
Provider Name (Legal Business Name): STACEY LEE RMHCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 45TH ST
MANGONIA PARK FL
33407-2413
US

IV. Provider business mailing address

933 45TH ST
MANGONIA PARK FL
33407-2413
US

V. Phone/Fax

Practice location:
  • Phone: 334-440-9819
  • Fax:
Mailing address:
  • Phone: 334-440-9819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH29608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: