Provider Demographics
NPI:1205329455
Name:TUSSINGER (SLACK), BROOKE ALYSSA
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALYSSA
Last Name:TUSSINGER (SLACK)
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 1:9000 SOUTHSIDE BLVD BLDG 900
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0791
Mailing Address - Country:US
Mailing Address - Phone:904-732-4343
Mailing Address - Fax:904-562-3466
Practice Address - Street 1:5625 SILVER SANDS CIR
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656
Practice Address - Country:US
Practice Address - Phone:352-214-3398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician