Healthcare Provider Details

I. General information

NPI: 1831001767
Provider Name (Legal Business Name): TYRA GABRIELLE SANDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 S FLORIDA AVE
LAKELAND FL
33813-1628
US

IV. Provider business mailing address

2685 WHISPERING TRAILS DR
WINTER HAVEN FL
33884-1844
US

V. Phone/Fax

Practice location:
  • Phone: 863-456-7148
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: