Healthcare Provider Details

I. General information

NPI: 1982351292
Provider Name (Legal Business Name): TAMARA LA ROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 NE PINE ISLAND RD STE 7E-F
CAPE CORAL FL
33909-2135
US

IV. Provider business mailing address

4819 ATLANTIC CT APT 5
CAPE CORAL FL
33904-9527
US

V. Phone/Fax

Practice location:
  • Phone: 239-599-8733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-124657
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: