Healthcare Provider Details

I. General information

NPI: 1275397622
Provider Name (Legal Business Name): SAN THAWALANTHANNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2290 N RONALD REAGAN BLVD STE 116
LONGWOOD FL
32750-3534
US

IV. Provider business mailing address

1000 S LAKE DR
CLEARWATER FL
33756-4415
US

V. Phone/Fax

Practice location:
  • Phone: 407-215-0095
  • Fax: 407-261-0523
Mailing address:
  • Phone: 815-451-2897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11031100
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: