Healthcare Provider Details

I. General information

NPI: 1124610464
Provider Name (Legal Business Name): PRESTIGE ABA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 FOWLER ST STE 3
FORT MYERS FL
33901-2616
US

IV. Provider business mailing address

4350 FOWLER ST STE 3
FORT MYERS FL
33901-2616
US

V. Phone/Fax

Practice location:
  • Phone: 786-317-0100
  • Fax: 813-776-1620
Mailing address:
  • Phone: 786-317-0100
  • Fax: 813-776-1620

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: MAIRELYS CONCEPCION
Title or Position: OWNER
Credential: RBT
Phone: 786-317-0100