Healthcare Provider Details

I. General information

NPI: 1881157162
Provider Name (Legal Business Name): MARIA REARDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date: 06/09/2021
Reactivation Date: 07/15/2021

III. Provider practice location address

220 W BRANDON BLVD STE 203
BRANDON FL
33511-5100
US

IV. Provider business mailing address

220 W BRANDON BLVD STE 203
BRANDON FL
33511-5100
US

V. Phone/Fax

Practice location:
  • Phone: 813-464-1007
  • Fax: 813-381-3909
Mailing address:
  • Phone: 813-464-1007
  • Fax: 813-381-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW16094
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: