Provider Demographics
NPI:1013212299
Name:PAWICH, TAMARA (PHD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:
Last Name:PAWICH
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 CENTER ST STE 231
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-3717
Mailing Address - Country:US
Mailing Address - Phone:321-282-1475
Mailing Address - Fax:
Practice Address - Street 1:166 CENTER ST STE 231
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-3717
Practice Address - Country:US
Practice Address - Phone:321-282-1475
Practice Address - Fax:321-473-7089
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8959103T00000X
1-09-5671103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018109300Medicaid