Healthcare Provider Details

I. General information

NPI: 1790561512
Provider Name (Legal Business Name): TIA REIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 CATALINA ST
TITUSVILLE FL
32796-2211
US

IV. Provider business mailing address

3895 S TROPICAL TRL
MERRITT ISLAND FL
32952-6137
US

V. Phone/Fax

Practice location:
  • Phone: 321-346-8450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-291791
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: