Healthcare Provider Details

I. General information

NPI: 1730059817
Provider Name (Legal Business Name): TYHESHA N WHITLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ARC DR
ST AUGUSTINE FL
32084-0512
US

IV. Provider business mailing address

304 N BELLAGIO DR
ST AUGUSTINE FL
32092-3477
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7249
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-13-5635
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: