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General NPI Number Information
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NPI Number | 1902477656
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Entity Type | Individual
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Provider Name | STALACIA COLLYMORE
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Gender | Female
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Dates
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Enumeration Date | 07/05/2021
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Last Update Date | 01/18/2022
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Provider Practice Location Address
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Address Line | 1765 SW CAPTAINS PL
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City | PALM CITY
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State | FL
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Zip | 34990-1747
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Country | US
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Telephone | 727-266-8727
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Fax | 772-494-7093
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Provider Business Mailing Address
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Address Line | 5981 VIA VERMILYA APT 103
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City | LANTANA
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State | FL
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Zip | 33462-2441
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Country | US
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Telephone | 561-425-4922
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-21-172803
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License Number State | FL
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