Provider Demographics
NPI:1023485992
Name:WHITE, TENNILLE ANN (MS,BCBA)
Entity type:Individual
Prefix:
First Name:TENNILLE
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MS,BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 ELKCAM BLVD.
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725
Mailing Address - Country:US
Mailing Address - Phone:502-650-0818
Mailing Address - Fax:
Practice Address - Street 1:1699 ELKCAM BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-3919
Practice Address - Country:US
Practice Address - Phone:502-650-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-25431103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst