=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851965339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STACY CARMICHAEL PHD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2021
-----------------------------------------------------
Last Update Date | 05/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 S DILLARD ST STE 160
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-415-1450
-----------------------------------------------------
Fax | 321-234-5587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 663 E PLANT ST
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-3144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-481-2444
-----------------------------------------------------
Fax | 321-234-5587
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STACY LYNN CARMICHAEL
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 407-415-1450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------