Healthcare Provider Details

I. General information

NPI: 1982396677
Provider Name (Legal Business Name): TYEESHA HERNDON B.S.,M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10272 S US HIGHWAY 1
PORT SAINT LUCIE FL
34952-5615
US

IV. Provider business mailing address

5403 NW CHICOPA ST
PORT SAINT LUCIE FL
34983-2335
US

V. Phone/Fax

Practice location:
  • Phone: 772-872-6940
  • Fax:
Mailing address:
  • Phone: 772-872-6940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1102735
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: