Healthcare Provider Details

I. General information

NPI: 1275452955
Provider Name (Legal Business Name): STEPHAN WAYNE MITCHELL ED.S., NCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 SE LAKE FALLS ST
PORT SAINT LUCIE FL
34984-6693
US

IV. Provider business mailing address

702 SE LAKE FALLS ST
PORT SAINT LUCIE FL
34984-6693
US

V. Phone/Fax

Practice location:
  • Phone: 561-202-1621
  • Fax:
Mailing address:
  • Phone: 561-202-1621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS1988
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: