Healthcare Provider Details

I. General information

NPI: 1336418417
Provider Name (Legal Business Name): PROGRESSIVE BEHAVIOR MANAGEMENT RES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 E BLOOMINGDALE AVE
BRANDON FL
33511-8111
US

IV. Provider business mailing address

220 W BRANDON BLVD SUITE 210
BRANDON FL
33511-5104
US

V. Phone/Fax

Practice location:
  • Phone: 813-525-5468
  • Fax: 813-438-8903
Mailing address:
  • Phone: 813-525-5468
  • Fax: 813-438-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 11898
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-07-3280
License Number StateFL

VIII. Authorized Official

Name: MS. STACEY DENISE SPARKMAN
Title or Position: OWNER/BCBA
Credential: BCBA
Phone: 813-525-5468