Provider Demographics
NPI:1477177905
Name:TANDY, BRAYSEN SCOTT (RBT)
Entity Type:Individual
Prefix:
First Name:BRAYSEN
Middle Name:SCOTT
Last Name:TANDY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-2482
Mailing Address - Country:US
Mailing Address - Phone:239-994-0029
Mailing Address - Fax:
Practice Address - Street 1:3900 COLONIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1014
Practice Address - Country:US
Practice Address - Phone:239-351-3715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-120074106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20-120074Medicaid