Healthcare Provider Details

I. General information

NPI: 1689454613
Provider Name (Legal Business Name): TREASURE COAST NEUROPSYCHOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2023
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10570 S US HIGHWAY 1 STE 300
PORT ST LUCIE FL
34952-5606
US

IV. Provider business mailing address

10570 S US HIGHWAY 1 STE 300
PORT ST LUCIE FL
34952-5606
US

V. Phone/Fax

Practice location:
  • Phone: 772-278-5508
  • Fax: 772-673-6225
Mailing address:
  • Phone: 772-278-5508
  • Fax: 772-673-6225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ASHLEY J TANTON
Title or Position: OWNER & CLINICAL NEUROPSYCHOLOGIST
Credential: PSY.D.
Phone: 772-278-5508