Provider Demographics
NPI:1508162116
Name:BOBO, TEQUILLA SCHANTEL
Entity Type:Individual
Prefix:
First Name:TEQUILLA
Middle Name:SCHANTEL
Last Name:BOBO
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 1:4107 W SPRUCE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2327
Mailing Address - Country:US
Mailing Address - Phone:813-636-8811
Mailing Address - Fax:813-636-8855
Practice Address - Street 1:4107 W SPRUCE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2327
Practice Address - Country:US
Practice Address - Phone:813-636-8811
Practice Address - Fax:813-636-8855
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH9987101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMCD01967500Medicaid