Provider Demographics
NPI:1922831973
Name:STADOM, ANTONIA TAMAYA
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:TAMAYA
Last Name:STADOM
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 1:750 CAROLIN ST APT 305
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3266
Mailing Address - Country:US
Mailing Address - Phone:321-557-7942
Mailing Address - Fax:
Practice Address - Street 1:1320 CULVER DR NE STE 3
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1104
Practice Address - Country:US
Practice Address - Phone:321-914-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPF-1723795404-25666106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician