Provider Demographics
NPI:1669906525
Name:CONNOR, TAMMY-LEE
Entity type:Individual
Prefix:MISS
First Name:TAMMY-LEE
Middle Name:
Last Name:CONNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TAMMY-LEE
Other - Middle Name:
Other - Last Name:BREAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2449 SW VARDON ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2445
Mailing Address - Country:US
Mailing Address - Phone:772-453-1458
Mailing Address - Fax:
Practice Address - Street 1:2449 SW VARDON ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2445
Practice Address - Country:US
Practice Address - Phone:772-453-1458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL247200000X106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL247200000XMedicaid