Healthcare Provider Details

I. General information

NPI: 1679286942
Provider Name (Legal Business Name): STACEY LATRICIA CANTY MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 NW 5TH ST
OKEECHOBEE FL
34972-2565
US

IV. Provider business mailing address

PO BOX 2452
BELLE GLADE FL
33430-7452
US

V. Phone/Fax

Practice location:
  • Phone: 561-616-8411
  • Fax:
Mailing address:
  • Phone: 561-707-1618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: