Healthcare Provider Details

I. General information

NPI: 1114793064
Provider Name (Legal Business Name): TIA DANIELLE HEPBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2023
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8291 DAMES POINT CROSSING BLVD N APT 4310
JACKSONVILLE FL
32277-3847
US

IV. Provider business mailing address

8291 DAMES POINT CROSSING BLVD N APT 4310
JACKSONVILLE FL
32277-3847
US

V. Phone/Fax

Practice location:
  • Phone: 480-662-2560
  • Fax:
Mailing address:
  • Phone: 480-662-2560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCBHT.0100424
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: