Healthcare Provider Details

I. General information

NPI: 1801711403
Provider Name (Legal Business Name): STEPHAN DIMITRJEVITCH APRN PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9885 SW 123RD TER
MIAMI FL
33176-4935
US

IV. Provider business mailing address

13818 SW 152ND ST # 216
MIAMI FL
33177-1164
US

V. Phone/Fax

Practice location:
  • Phone: 786-801-7095
  • Fax:
Mailing address:
  • Phone: 786-801-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11049967
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: