Provider Demographics
NPI:1831860535
Name:HARGROVE, JULIA TAWNEY
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:TAWNEY
Last Name:HARGROVE
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:PO BOX 2474
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32781-2474
Mailing Address - Country:US
Mailing Address - Phone:321-225-9374
Mailing Address - Fax:
Practice Address - Street 1:4647 CLYDE MORRIS BLVD UNIT 501
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-3001
Practice Address - Country:US
Practice Address - Phone:286-767-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-185170106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician