Healthcare Provider Details

I. General information

NPI: 1548771496
Provider Name (Legal Business Name): AUTHENTIC LIFE TRANSITIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 ALOMA AVE STE 204
WINTER PARK FL
32792-3752
US

IV. Provider business mailing address

3001 ALOMA AVE STE 204
WINTER PARK FL
32792-3752
US

V. Phone/Fax

Practice location:
  • Phone: 321-420-6095
  • Fax: 407-530-1935
Mailing address:
  • Phone: 321-420-6095
  • Fax: 407-530-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY9160
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY9160
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY9160
License Number StateFL

VIII. Authorized Official

Name: DR. STEPHANY LYNNE MAHAFFEY
Title or Position: LICENSED PSYCHOLOGIST
Credential: PHD
Phone: 940-453-0872