Healthcare Provider Details

I. General information

NPI: 1679317366
Provider Name (Legal Business Name): SARAH STUPP MA, RMHCI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 SUNTREE BLVD STE 103A
MELBOURNE FL
32940-7540
US

IV. Provider business mailing address

330 ALABAMA AVE
MERRITT ISLAND FL
32953-3307
US

V. Phone/Fax

Practice location:
  • Phone: 321-757-4015
  • Fax:
Mailing address:
  • Phone: 919-593-2971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH25988
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: