MEDICARE: DR. STEPHANIE DIANE CREEDON PHD

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	103T00000X	Psychologist	PY6156	FL

General Provider Information

NPI Number	:	1619149002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHANIE DIANE CREEDON PHD

Provider Business Mailing Address
First Line	:	13591 CALOOSA BLVD
Second Line	:
City	:	PALM BCH GARDENS
State	:	FL
Zip	:	33418
Country	:	US
Telephone Number	:	561-694-0622
Fax Number	:	561-624-9720

Provider Business Practice Location Address
First Line	:	3378 FOREST HILL BLVD
Second Line	:	STE A-203 PALM BCH COUNTY SCHOOL DISTRICT
City	:	PALM BCH GARDENS
State	:	FL
Zip	:	33406
Country	:	US
Telephone Number	:	561-379-5785
Fax Number	:

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

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	03/26/2008

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