Healthcare Provider Details

I. General information

NPI: 1992483176
Provider Name (Legal Business Name): ROBERT MANFRED NELSON IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14509 DEL VALLE RD
TAMPA FL
33625-1445
US

IV. Provider business mailing address

14509 DEL VALLE RD
TAMPA FL
33625-1445
US

V. Phone/Fax

Practice location:
  • Phone: 813-514-3484
  • Fax:
Mailing address:
  • Phone: 813-514-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-26-17210
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: