Healthcare Provider Details

I. General information

NPI: 1629448832
Provider Name (Legal Business Name): TARA RENBECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 LAKEWOOD RD
JACKSONVILLE FL
32207-5316
US

IV. Provider business mailing address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

V. Phone/Fax

Practice location:
  • Phone: 904-610-8926
  • Fax:
Mailing address:
  • Phone: 904-360-7022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA9561
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: