Provider Demographics
NPI:1285722538
Name:PORRECA, TINA (MS,CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:PORRECA
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16697 SHELL BAY DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-5749
Mailing Address - Country:US
Mailing Address - Phone:727-631-2466
Mailing Address - Fax:813-345-2896
Practice Address - Street 1:16697 SHELL BAY DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-5749
Practice Address - Country:US
Practice Address - Phone:727-631-2466
Practice Address - Fax:813-345-2896
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8085222Q00000X
FLSA8085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890827300Medicaid
FLFT923ZOtherMEDICARE PTAN NUMBER
FLS3069OtherBC/BS OF FLORIDA #
FL010713100Medicaid
FL010713100Other222Q00000X EARLY INTERVENTIONIST