Healthcare Provider Details

I. General information

NPI: 1275916926
Provider Name (Legal Business Name): JEANINE TANZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 MURRELL RD STE 100
MELBOURNE FL
32940-6700
US

IV. Provider business mailing address

5500 MURRELL ROAD
MELBOURNE FL
32940
US

V. Phone/Fax

Practice location:
  • Phone: 321-426-7759
  • Fax: 321-593-0839
Mailing address:
  • Phone: 321-426-7759
  • Fax: 321-593-0839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11410404
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: