Provider Demographics
NPI:1376822981
Name:TANTILLO, DEBRA J
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:J
Last Name:TANTILLO
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 1:333 NW 46TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-4010
Mailing Address - Country:US
Mailing Address - Phone:954-732-5418
Mailing Address - Fax:954-772-1023
Practice Address - Street 1:3115 NW 10TH TER STE 103
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-5937
Practice Address - Country:US
Practice Address - Phone:954-236-6676
Practice Address - Fax:954-772-1023
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW55381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical