Provider Demographics
NPI:1275987497
Name:TISDALE, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13815 DEVAN LEE DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-5868
Mailing Address - Country:US
Mailing Address - Phone:904-613-5005
Mailing Address - Fax:904-696-9868
Practice Address - Street 1:13815 DEVAN LEE DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-5868
Practice Address - Country:US
Practice Address - Phone:904-613-5005
Practice Address - Fax:904-696-9868
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-56676103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst