Healthcare Provider Details

I. General information

NPI: 1245082650
Provider Name (Legal Business Name): EARLY WINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 STEWART PARK LN
DELAND FL
32724-7729
US

IV. Provider business mailing address

408 STEWART PARK LN
DELAND FL
32724-7729
US

V. Phone/Fax

Practice location:
  • Phone: 786-620-7367
  • Fax:
Mailing address:
  • Phone:
  • 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 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: ARIEL TAPANES DOMINGUEZ
Title or Position: BCBA / OWNER
Credential: BCBA
Phone: 786-620-7367