MEDICARE: STACEY SANTAGATA BCBA

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	103K00000X	Behavior Analyst	1-15-21193	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750738746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY SANTAGATA BCBA

Provider Business Mailing Address
First Line	:	5 REVERE DR STE 120
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-8005
Country	:	US
Telephone Number	:	941-416-4338
Fax Number	:

Provider Business Practice Location Address
First Line	:	2565 N TOLEDO BLADE BLVD
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34289-9306
Country	:	US
Telephone Number	:	941-416-4338
Fax Number	:

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

Provider Enumeration Date	:	05/19/2016
Last Update Date	:	07/30/2019

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