Healthcare Provider Details

I. General information

NPI: 1396017414
Provider Name (Legal Business Name): SOUTHLAKE AUTISM AND BEHAVIOR SERVICES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2012
Last Update Date: 05/05/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ACCEPTANCE WAY
CLERMONT FL
34711
US

IV. Provider business mailing address

13201 SUGARBLUFF RD
CLERMONT FL
34715-6819
US

V. Phone/Fax

Practice location:
  • Phone: 352-223-1999
  • Fax:
Mailing address:
  • Phone: 352-978-5903
  • Fax: 352-600-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0-11-4087
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number0-11-4087
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0-11-4087
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number0-11-4087
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number0-11-4087
License Number StateFL

VIII. Authorized Official

Name: MRS. TERRI HOWARD
Title or Position: CLINICAL DIRECTOR/BEHAVIOR ANALYST
Credential: BCBA
Phone: 352-223-1999