Provider Demographics
NPI:1093503310
Name:PETERKIN, STACEY LAUREIN (BT)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LAUREIN
Last Name:PETERKIN
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 NW HATCHES HARBOR RD APT 206
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-4106
Mailing Address - Country:US
Mailing Address - Phone:772-882-1129
Mailing Address - Fax:
Practice Address - Street 1:900 SE OCEAN BLVD STE 230D
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3501
Practice Address - Country:US
Practice Address - Phone:772-215-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician