MEDICARE: THE ABA LOFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1578391066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE ABA LOFT

Provider Business Mailing Address
First Line	:	4273 SW MCCLELLEN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6135
Country	:	US
Telephone Number	:	561-398-5309
Fax Number	:

Provider Business Practice Location Address
First Line	:	4273 SW MCCLELLEN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6135
Country	:	US
Telephone Number	:	772-233-6446
Fax Number	:	772-264-7995

Authorized Official
Title or Position	:	BCBA, OWNER, FOUNDER
Name	:	MRS. SHANNON SIMONE PRINCE
Credential	:	BCBA
Telephone Number	:	561-398-5309

Provider Enumeration Date	:	07/25/2024
Last Update Date	:	07/25/2024

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Directions to “THE ABA LOFT ” Practice Location

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