Provider Demographics
NPI:1619065877
Name:JOPLIN, TENNILLE
Entity Type:Individual
Prefix:MS
First Name:TENNILLE
Middle Name:
Last Name:JOPLIN
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 1:3433 LITHIA PINECREST RD STE 135
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-6302
Mailing Address - Country:US
Mailing Address - Phone:813-391-8398
Mailing Address - Fax:
Practice Address - Street 1:3334 LITHIA PINECREST RD STE 135
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596
Practice Address - Country:US
Practice Address - Phone:813-391-8398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA7641235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889910001Medicaid
FL812056100Medicaid
FLS2909OtherBC/BS OF FLORIDA #
FL812056100Medicaid