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NPI Code Detail

MEDICARE: BROOKE ALYSSA TUSSINGER (SLACK)

MEDICARE: BROOKE ALYSSA TUSSINGER (SLACK)
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1205329455
Entity Type Code : Individual
Provider Name (Legal Business Name) : BROOKE ALYSSA TUSSINGER (SLACK)
Provider Business Mailing Address
First Line : 9000 SOUTHSIDE BLVD BLDG 900
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32256-0791
Country : US
Telephone Number : 904-732-4343
Fax Number : 904-562-3466
Provider Business Practice Location Address
First Line : 5625 SILVER SANDS CIR
Second Line :
City : KEYSTONE HEIGHTS
State : FL
Zip : 32656
Country : US
Telephone Number : 352-214-3398
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/12/2018
Last Update Date : 05/27/2021

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Directions to “ BROOKE ALYSSA TUSSINGER (SLACK) ” Practice Location

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