Basic Information
| Provider Information | |||||||||
| NPI: | 1447717913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEBOSE | ||||||||
| FirstName: | TIJUANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1094 STRATTON AVE | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346096462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135629074 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10909 MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336152511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138554435 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2019 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106S00000X | Y |
No ID Information.