Provider Demographics
NPI:1922537687
Name:ANTONIO-WELDON, TRACEY JAYNE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:JAYNE
Last Name:ANTONIO-WELDON
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 1:7398 MEAD DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-4319
Mailing Address - Country:US
Mailing Address - Phone:352-606-8174
Mailing Address - Fax:
Practice Address - Street 1:7398 MEAD DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-4319
Practice Address - Country:US
Practice Address - Phone:352-606-8174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA535810807161106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid