MEDICARE: STANIE MESAMOUR

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	106S00000X	Behavior Technician	RBT-23-297089	FL

General Provider Information

NPI Number	:	1104607464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STANIE MESAMOUR

Provider Business Mailing Address
First Line	:	9648 WINDSOR GARDENS LN APT 202
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-8402
Country	:	US
Telephone Number	:	754-213-9795
Fax Number	:

Provider Business Practice Location Address
First Line	:	9648 WINDSOR GARDENS LN APT 202
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-8402
Country	:	US
Telephone Number	:	754-213-9795
Fax Number	:

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

Provider Enumeration Date	:	10/11/2023
Last Update Date	:	10/11/2023

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Directions to “ STANIE MESAMOUR ” Practice Location

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