Basic Information
| Provider Information | |||||||||
| NPI: | 1356707327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOBON | ||||||||
| FirstName: | VANESSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 979 ALEXIA ST | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329353121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212133340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 709 S HARBOR CITY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218025814 | ||||||||
| FaxNumber: | 3218025811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2016 | ||||||||
| LastUpdateDate: | 12/10/2018 | ||||||||
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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 | 225X00000X | OT17052 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | GC44C | 01 | FL | FLORIDA BLUE | OTHER |