Healthcare Provider Details

I. General information

NPI: 1003330515
Provider Name (Legal Business Name): SHERIDAN TIHISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4817 EHRLICH RD
TAMPA FL
33624-2037
US

IV. Provider business mailing address

PO BOX 357370
GAINESVILLE FL
32635-7370
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-8588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: