Provider Demographics
NPI:1568812881
Name:DRUMMOND, STACY WHITTED
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:WHITTED
Last Name:DRUMMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:WHITTED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3406 W SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629
Mailing Address - Country:US
Mailing Address - Phone:904-710-1547
Mailing Address - Fax:813-512-2734
Practice Address - Street 1:3406 W SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629
Practice Address - Country:US
Practice Address - Phone:904-710-1547
Practice Address - Fax:813-512-2734
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL1-21-55830103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid
FL11325300Medicaid