Basic Information
| Provider Information | |||||||||
| NPI: | 1891224291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATEBEFIA | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GAGE | ||||||||
| OtherFirstName: | STACY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2121 BURWICK AVE APT 2607 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320738798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5858310028 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5776 SAINT AUGUSTINE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044484700 | ||||||||
| FaxNumber: | 9044484717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2017 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | NY | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | SW20308 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.