Healthcare Provider Details

I. General information

NPI: 1205811064
Provider Name (Legal Business Name): TINA DAWN HALLAUER MA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W VINE ST SUITE 266
KISSIMMEE FL
34741-4643
US

IV. Provider business mailing address

3501 W VINE ST SUITE 266
KISSIMMEE FL
34741-4643
US

V. Phone/Fax

Practice location:
  • Phone: 407-846-4111
  • Fax: 407-846-8088
Mailing address:
  • Phone: 407-846-4111
  • Fax: 407-846-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMH7530
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: