Healthcare Provider Details

I. General information

NPI: 1811154933
Provider Name (Legal Business Name): TAMPA BAY ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12012 BOYETTE RD
RIVERVIEW FL
33569-5631
US

IV. Provider business mailing address

12012 BOYETTE RD
RIVERVIEW FL
33569-5631
US

V. Phone/Fax

Practice location:
  • Phone: 813-677-6700
  • Fax: 813-671-3145
Mailing address:
  • Phone: 813-677-6700
  • Fax: 813-671-3145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMH9004
License Number StateFL

VIII. Authorized Official

Name: MRS. BOBBY JEAN COOPER
Title or Position: THERAPIST
Credential: LMHC
Phone: 813-677-6700