Provider Demographics
NPI:1669246120
Name:GRESHAM, TA'LIA
Entity type:Individual
Prefix:
First Name:TA'LIA
Middle Name:
Last Name:GRESHAM
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 1:3405 PINEWALK DR N BUILDING 9 UNIT 109
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7451 WILES RD STE 107
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-2040
Practice Address - Country:US
Practice Address - Phone:954-893-2442
Practice Address - Fax:954-516-7631
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician