Provider Demographics
NPI:1386766863
Name:STANSBERRY, JOHN MATTHEW
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MATTHEW
Last Name:STANSBERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11404 MALLORY SQUARE DR
Mailing Address - Street 2:BOX 203
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-6352
Mailing Address - Country:US
Mailing Address - Phone:812-664-6242
Mailing Address - Fax:
Practice Address - Street 1:13515 86TH AVE
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-2630
Practice Address - Country:US
Practice Address - Phone:727-423-5708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker