Healthcare Provider Details

I. General information

NPI: 1639769276
Provider Name (Legal Business Name): MY ABA FAMILY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2021
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 WILSHIRE BLVD STE 155
CASSELBERRY FL
32707-5362
US

IV. Provider business mailing address

10308 BROWNWOOD AVE
ORLANDO FL
32825-6628
US

V. Phone/Fax

Practice location:
  • Phone: 203-510-9325
  • Fax: 407-704-2556
Mailing address:
  • Phone: 203-228-7577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. YANKO BERMUDEZ VILLA
Title or Position: AMBR
Credential:
Phone: 203-510-9325