Healthcare Provider Details

I. General information

NPI: 1902405830
Provider Name (Legal Business Name): TEJAH CARBONE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 S TANNER RD
ORLANDO FL
32820-1202
US

IV. Provider business mailing address

2630 S TANNER RD
ORLANDO FL
32820-1202
US

V. Phone/Fax

Practice location:
  • Phone: 407-257-5015
  • Fax:
Mailing address:
  • Phone: 407-257-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11323
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: