Provider Demographics
NPI:1881157162
Name:REARDON, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:REARDON
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 1:220 W BRANDON BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5100
Mailing Address - Country:US
Mailing Address - Phone:813-464-1007
Mailing Address - Fax:813-381-3909
Practice Address - Street 1:220 W BRANDON BLVD STE 203
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5100
Practice Address - Country:US
Practice Address - Phone:813-464-1007
Practice Address - Fax:813-381-3909
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2021-12-06
Deactivation Date:2021-06-09
Deactivation Code:
Reactivation Date:2021-07-15
Provider Licenses
StateLicense IDTaxonomies
FLSW160941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102764000Medicaid