Healthcare Provider Details

I. General information

NPI: 1104509744
Provider Name (Legal Business Name): THEODORE SAMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5768 S SEMORAN BLVD
ORLANDO FL
32822-4818
US

IV. Provider business mailing address

5766 S SEMORAN BLVD
ORLANDO FL
32822-4818
US

V. Phone/Fax

Practice location:
  • Phone: 772-203-5788
  • Fax: 888-469-2740
Mailing address:
  • Phone: 772-203-5788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: