Healthcare Provider Details

I. General information

NPI: 1669831723
Provider Name (Legal Business Name): TINY LITTLE JEWELS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 VINE CLIFF ST
RUSKIN FL
33570-4935
US

IV. Provider business mailing address

PO BOX 6823
TAMPA FL
33608-0823
US

V. Phone/Fax

Practice location:
  • Phone: 813-609-2655
  • Fax:
Mailing address:
  • Phone: 813-609-2655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 12868
License Number StateFL

VIII. Authorized Official

Name: TANYA JOHNSON-GILCHRIST
Title or Position: OWNER
Credential: LCSW, MSW, MPH, CPH
Phone: 813-609-2655