MEDICARE: TYLER LEA KEESECKER

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
1	106S00000X	Behavior Technician		FL
2	103K00000X	Behavior Analyst	1-20-45292	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346747821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER LEA KEESECKER

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:	407-915-7729
Fax Number	:

Provider Business Practice Location Address
First Line	:	2389 OAK MYRTLE LN
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-6328
Country	:	US
Telephone Number	:	813-862-3030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2018
Last Update Date	:	03/07/2023

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