Healthcare Provider Details

I. General information

NPI: 1528995685
Provider Name (Legal Business Name): VIVID BEHAVIOR SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 CHAMPAGNE AVE
GULF BREEZE FL
32563-9039
US

IV. Provider business mailing address

1617 CHAMPAGNE AVE
GULF BREEZE FL
32563-9039
US

V. Phone/Fax

Practice location:
  • Phone: 850-384-1131
  • Fax:
Mailing address:
  • Phone: 850-384-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA LEE BASS
Title or Position: OWNER
Credential: BCBA
Phone: 850-384-1131