Provider Demographics
NPI:1114943594
Name:COLLABORATIVE FUNCTION
Entity Type:Organization
Organization Name:COLLABORATIVE FUNCTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/VP/SEC. & SPEECH-LANGUAGE PATH
Authorized Official - Prefix:MS
Authorized Official - First Name:AMIE
Authorized Official - Middle Name:HANNA
Authorized Official - Last Name:TISHKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MACCC-SLP
Authorized Official - Phone:407-540-1937
Mailing Address - Street 1:726 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-7344
Mailing Address - Country:US
Mailing Address - Phone:407-540-1937
Mailing Address - Fax:407-540-1938
Practice Address - Street 1:726 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7344
Practice Address - Country:US
Practice Address - Phone:407-540-1937
Practice Address - Fax:407-540-1938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 5270225X00000X
FLSA 2744235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL885998100Medicaid