MEDICARE: MS. SAMANTHA TYLER

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

General Provider Information

NPI Number	:	1457880304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SAMANTHA TYLER

Provider Business Mailing Address
First Line	:	175 MIDDLE ST UNIT 1201
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3625
Country	:	US
Telephone Number	:	866-610-0580
Fax Number	:

Provider Business Practice Location Address
First Line	:	17435 US HIGHWAY 441 STE 101
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-6750
Country	:	US
Telephone Number	:	352-434-0455
Fax Number	:

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

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	06/05/2017

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