Healthcare Provider Details

I. General information

NPI: 1932621810
Provider Name (Legal Business Name): BEHAVIORAL INDEPENDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 MOSELEY AVE
PALATKA FL
32177-4937
US

IV. Provider business mailing address

504 MOSELEY AVE
PALATKA FL
32177-4937
US

V. Phone/Fax

Practice location:
  • Phone: 386-562-0170
  • Fax:
Mailing address:
  • Phone: 386-562-0170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-08-4879
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMANDA ELLEN LANG
Title or Position: CEO
Credential: BCBA
Phone: 386-562-0170