Healthcare Provider Details

I. General information

NPI: 1912565409
Provider Name (Legal Business Name): TA'CHARA BURNSIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 GULF BREEZE PKWY
GULF BREEZE FL
32563-3350
US

IV. Provider business mailing address

3208 GULF BREEZE PKWY
GULF BREEZE FL
32563-3350
US

V. Phone/Fax

Practice location:
  • Phone: 800-676-5130
  • Fax: 888-958-5753
Mailing address:
  • Phone: 800-676-5130
  • Fax: 888-958-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: