Healthcare Provider Details

I. General information

NPI: 1154891836
Provider Name (Legal Business Name): LAURA DEZAYAS BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 10/24/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 NW 89TH BLVD
GAINESVILLE FL
32606-3813
US

IV. Provider business mailing address

300 INTERNATIONAL PARKWAY STE 200
LAKE MARY FL
32746
US

V. Phone/Fax

Practice location:
  • Phone: 352-554-9162
  • Fax: 352-608-9203
Mailing address:
  • Phone: 407-915-7729
  • Fax: 407-588-6294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-19-10487
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1620049
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12261940
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: