Provider Demographics
NPI:1639823842
Name:TEBOE, ELIJAH
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:TEBOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 TRAWICK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:FL
Mailing Address - Zip Code:32564-9527
Mailing Address - Country:US
Mailing Address - Phone:850-612-2548
Mailing Address - Fax:
Practice Address - Street 1:973 TRAWICK CREEK RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:FL
Practice Address - Zip Code:32564-9527
Practice Address - Country:US
Practice Address - Phone:850-612-2548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician