Provider Demographics
NPI:1578390571
Name:GARCIA, TEDDY
Entity type:Individual
Prefix:
First Name:TEDDY
Middle Name:
Last Name:GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13581 EAGLE RIDGE DR APT 1426
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-6814
Mailing Address - Country:US
Mailing Address - Phone:239-895-4058
Mailing Address - Fax:
Practice Address - Street 1:28410 BONITA CROSSINGS BLVD UNIT 150
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-3217
Practice Address - Country:US
Practice Address - Phone:239-451-7163
Practice Address - Fax:239-310-2045
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-377333106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician