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General NPI Number Information
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NPI Number | 1174796296
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Entity Type | Individual
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Provider Name | JOHN ANTHONY TALLARIDO LCSW
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Gender | Male
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Dates
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Enumeration Date | 04/09/2008
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Last Update Date | 12/13/2016
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Provider Practice Location Address
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Address Line | 130 S INDIAN RIVER DR SUITE 202
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City | FORT PIERCE
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State | FL
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Zip | 34950-4343
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Country | US
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Telephone | 561-422-0900
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Fax | 561-584-5155
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Provider Business Mailing Address
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Address Line | 313 SW TOMOKA SPRINGS DR
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-1918
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Country | US
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Telephone | 561-422-0900
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Fax | 561-584-5155
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW7234
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License Number State | FL
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