Healthcare Provider Details

I. General information

NPI: 1245717560
Provider Name (Legal Business Name): TEAGAN LEIGH RUMMELT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 3RD ST
SHALIMAR FL
32579-1377
US

IV. Provider business mailing address

PO BOX 259
SHALIMAR FL
32579-0259
US

V. Phone/Fax

Practice location:
  • Phone: 850-362-6824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-60980
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: