Provider Demographics
NPI:1942904123
Name:TABER-RICHARDSON, ROWAN ELISE
Entity Type:Individual
Prefix:
First Name:ROWAN
Middle Name:ELISE
Last Name:TABER-RICHARDSON
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 1:18629 TAMPA RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-3530
Mailing Address - Country:US
Mailing Address - Phone:239-766-9579
Mailing Address - Fax:
Practice Address - Street 1:300 INTERNATIONAL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5028
Practice Address - Country:US
Practice Address - Phone:239-766-9579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician