MEDICARE: STACY KEY COLLINS RBT

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	19-78184	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	:	1750842027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY KEY COLLINS RBT

Provider Business Mailing Address
First Line	:	2763 SANDRIDGE CHURCH RD
Second Line	:
City	:	GRAND RIDGE
State	:	FL
Zip	:	32442-4359
Country	:	US
Telephone Number	:	850-593-0078
Fax Number	:

Provider Business Practice Location Address
First Line	:	2763 SANDRIDGE CHURCH RD
Second Line	:
City	:	GRAND RIDGE
State	:	FL
Zip	:	32442-4359
Country	:	US
Telephone Number	:	850-593-0078
Fax Number	:

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

Provider Enumeration Date	:	03/28/2019
Last Update Date	:	03/28/2019

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