Healthcare Provider Details

I. General information

NPI: 1679114920
Provider Name (Legal Business Name): SAMUEL JUDD BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 CELEBRATION BLVD STE 104
CELEBRATION FL
34747-4604
US

IV. Provider business mailing address

4620 N STATE ROAD 7 STE 300
LAUDERDALE LAKES FL
33319-5867
US

V. Phone/Fax

Practice location:
  • Phone: 407-647-6555
  • Fax:
Mailing address:
  • Phone: 304-707-5510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-23-14623
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-71059
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: