Provider Demographics
NPI:1992447825
Name:STOCKENBERG, MEGAN NICHOLE
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:NICHOLE
Last Name:STOCKENBERG
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 1:1540 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-8632
Mailing Address - Country:US
Mailing Address - Phone:863-243-1243
Mailing Address - Fax:
Practice Address - Street 1:326 N RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-7205
Practice Address - Country:US
Practice Address - Phone:844-373-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-208662106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician