Provider Demographics
NPI:1689813958
Name:TOOT, THERESA L (LMHC, BCBA)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:L
Last Name:TOOT
Suffix:
Gender:F
Credentials:LMHC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 BARTRAM PARK BLVD UNIT 701
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5292
Mailing Address - Country:US
Mailing Address - Phone:321-720-6288
Mailing Address - Fax:
Practice Address - Street 1:175 CUMBERLAND PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8955
Practice Address - Country:US
Practice Address - Phone:321-720-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10600101YM0800X
FL1-07-3418103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health