Healthcare Provider Details

I. General information

NPI: 1629505151
Provider Name (Legal Business Name): QWENTON GUDE RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 BEATY GROVE DR
TAMPA FL
33626-1602
US

IV. Provider business mailing address

8001 BEATY GROVE DR
TAMPA FL
33626-1602
US

V. Phone/Fax

Practice location:
  • Phone: 813-403-0993
  • Fax:
Mailing address:
  • Phone: 813-403-0993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-77677
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: