Provider Demographics
NPI:1174796296
Name:TALLARIDO, JOHN ANTHONY (LCSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:TALLARIDO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 SW TOMOKA SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1918
Mailing Address - Country:US
Mailing Address - Phone:561-422-0900
Mailing Address - Fax:561-584-5155
Practice Address - Street 1:130 S INDIAN RIVER DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4343
Practice Address - Country:US
Practice Address - Phone:561-422-0900
Practice Address - Fax:561-584-5155
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW72341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU2000OtherMEDICARE PTAN