Provider Demographics
NPI:1326529462
Name:TYSZKIEWICZ, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:TYSZKIEWICZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 SW SANDY WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2083
Mailing Address - Country:US
Mailing Address - Phone:772-251-8500
Mailing Address - Fax:
Practice Address - Street 1:900 SE OCEAN BLVD STE 130D
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3503
Practice Address - Country:US
Practice Address - Phone:772-219-7575
Practice Address - Fax:855-457-4263
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician