=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568012318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER RYAN RETZLOFF RBT, QASP-S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2019
-----------------------------------------------------
Last Update Date | 08/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7552 NAVARRE PKWY UNIT 62
-----------------------------------------------------
City | NAVARRE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32566-7305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-607-6910
-----------------------------------------------------
Fax | 850-607-6932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 HUMMINGBIRD AVE NW
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32548-4345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-586-3182
-----------------------------------------------------
Fax | 850-607-6932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-19-98977
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106E00000X
-----------------------------------------------------
Taxonomy Name | Assistant Behavior Analyst
-----------------------------------------------------
License Number | QASP-S-11446
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------