MEDICARE: BLUE SPRIG PEDIATRICS, INC

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	:	1831892843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE SPRIG PEDIATRICS, INC

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:	833-288-4761
Fax Number	:	346-261-0052

Provider Business Practice Location Address
First Line	:	14765 W MOUNTAIN VIEW BLVD STE 107
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85374-2704
Country	:	US
Telephone Number	:	602-649-0245
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	MARKALISE MITCHELL
Credential	:
Telephone Number	:	281-541-8674

Provider Enumeration Date	:	03/27/2023
Last Update Date	:	03/03/2026

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