Provider Demographics
NPI:1568012318
Name:RETZLOFF, TYLER RYAN (RBT, QASP-S)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:RYAN
Last Name:RETZLOFF
Suffix:
Gender:M
Credentials:RBT, QASP-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HUMMINGBIRD AVE NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4345
Mailing Address - Country:US
Mailing Address - Phone:850-586-3182
Mailing Address - Fax:850-607-6932
Practice Address - Street 1:7552 NAVARRE PKWY UNIT 62
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7305
Practice Address - Country:US
Practice Address - Phone:850-607-6910
Practice Address - Fax:850-607-6932
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-98977106S00000X
FLQASP-S-11446106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician