Provider Demographics
NPI:1396266326
Name:DESRUISSEAUX, TAMARA SARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:SARA
Last Name:DESRUISSEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TOULON DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-7021
Mailing Address - Country:US
Mailing Address - Phone:863-978-2910
Mailing Address - Fax:
Practice Address - Street 1:907 OUTER RD STE B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6601
Practice Address - Country:US
Practice Address - Phone:352-577-8602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12147762103K00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst