Provider Demographics
NPI:1811555220
Name:OKONJI, TANISHA (MED, RBT)
Entity Type:Individual
Prefix:MRS
First Name:TANISHA
Middle Name:
Last Name:OKONJI
Suffix:
Gender:F
Credentials:MED, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 SILVER BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-4238
Mailing Address - Country:US
Mailing Address - Phone:904-450-9390
Mailing Address - Fax:
Practice Address - Street 1:3707 SILVER BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-4238
Practice Address - Country:US
Practice Address - Phone:904-450-9390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-87832247000000X
1-20-45941103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information