Healthcare Provider Details

I. General information

NPI: 1316522121
Provider Name (Legal Business Name): TYLER BRANDON COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5530
US

IV. Provider business mailing address

2041 DOGWOOD ST NE
PALM BAY FL
32907-2550
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax: 772-219-1339
Mailing address:
  • Phone: 717-747-6302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number23-255890
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-81694
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: