Provider Demographics
NPI:1518657048
Name:BERLETH, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BERLETH
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 1:1050 LARKIN RD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608-7459
Mailing Address - Country:US
Mailing Address - Phone:727-378-4182
Mailing Address - Fax:727-378-4272
Practice Address - Street 1:13733 OFFICE PARK CT
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7144
Practice Address - Country:US
Practice Address - Phone:727-378-4182
Practice Address - Fax:727-378-4272
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23272788106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician