MEDICARE: ALLISON DIANE HEBERT STAINTON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW12457	FL

General Provider Information

NPI Number	:	1003291337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLISON DIANE HEBERT STAINTON LCSW

Provider Business Mailing Address
First Line	:	11235 GRAND WINTHROP AVE
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33578-4671
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6152 DELANCEY STATION ST STE 206
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33578
Country	:	US
Telephone Number	:	813-445-6122
Fax Number	:	813-445-6122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2015
Last Update Date	:	05/24/2018

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