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General NPI Number Information
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NPI Number | 1275397622
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Entity Type | Individual
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Provider Name | SAN THAWALANTHANNE
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Gender | Male
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Dates
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Enumeration Date | 02/07/2024
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 2290 N RONALD REAGAN BLVD STE 116
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City | LONGWOOD
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State | FL
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Zip | 32750-3534
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Country | US
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Telephone | 407-215-0095
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Fax | 407-261-0523
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Provider Business Mailing Address
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Address Line | 1000 S LAKE DR
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City | CLEARWATER
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State | FL
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Zip | 33756-4415
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Country | US
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Telephone | 815-451-2897
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 11031100
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License Number State | FL
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