Provider Demographics
NPI:1588966907
Name:DEFOREST, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 W EAU GALLIE BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7213
Mailing Address - Country:US
Mailing Address - Phone:321-752-3197
Mailing Address - Fax:
Practice Address - Street 1:4450 W EAU GALLIE BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7213
Practice Address - Country:US
Practice Address - Phone:321-752-3197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health