Provider Demographics
NPI:1689813958
Name:TOOT, THERESA (MA, BCBA)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:TOOT
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 BIANCA DR NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5701
Mailing Address - Country:US
Mailing Address - Phone:321-720-6288
Mailing Address - Fax:
Practice Address - Street 1:750 BIANCA DR NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5701
Practice Address - Country:US
Practice Address - Phone:321-720-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 5301101YM0800X
FL1-07-3418103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health