Basic Information
| Provider Information | |||||||||
| NPI: | 1285722538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORRECA | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S.,CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16539 LAKE BRIGADOON CIR | ||||||||
| Address2: | SPEECH CONNECTION LLC | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336181146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276312466 | ||||||||
| FaxNumber: | 8133452896 | ||||||||
| Practice Location | |||||||||
| Address1: | 16539 LAKE BRIGADOON CIR | ||||||||
| Address2: | SPEECH CONNECTION LLC | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336181146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276312466 | ||||||||
| FaxNumber: | 8133452896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA8085 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 222Q00000X | SA 8085 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 010713100 | 01 | FL | 222Q00000X EARLY INTERVENTIONIST | OTHER | S3069 | 01 | FL | BC/BS OF FLORIDA # | OTHER | FT923Z | 01 | FL | MEDICARE PTAN NUMBER | OTHER | 010713100 | 05 | FL | MEDICAID | 890827300 | 05 | FL | MEDICAID |