Healthcare Provider Details

I. General information

NPI: 1467153338
Provider Name (Legal Business Name): THE VILLAGE ABA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 HOSPITAL DR NE
FORT WALTON BEACH FL
32548-5063
US

IV. Provider business mailing address

PO BOX 6105
NAVARRE FL
32566-1705
US

V. Phone/Fax

Practice location:
  • Phone: 850-533-9156
  • Fax: 850-347-2029
Mailing address:
  • Phone: 850-533-9156
  • Fax: 850-347-2029

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: MR. MICAH TERRELL SUTTON
Title or Position: PRESIDENT
Credential:
Phone: 850-533-9156