Healthcare Provider Details

I. General information

NPI: 1629497128
Provider Name (Legal Business Name): LORILEE TSAMOUTALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2014
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 W FLORIDA AVE
MELBOURNE FL
32904-7607
US

IV. Provider business mailing address

3075 W FLORIDA AVE
MELBOURNE FL
32904-7607
US

V. Phone/Fax

Practice location:
  • Phone: 321-795-9324
  • Fax: 772-675-9100
Mailing address:
  • Phone: 321-795-9324
  • Fax: 772-675-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: