Provider Demographics
NPI:1184034050
Name:TEJERA, VIVIAN
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:TEJERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:
Other - Last Name:LACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:467 BISCAYNE AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1716
Mailing Address - Country:US
Mailing Address - Phone:321-525-2476
Mailing Address - Fax:
Practice Address - Street 1:467 BISCAYNE AVE NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1716
Practice Address - Country:US
Practice Address - Phone:321-525-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker