Healthcare Provider Details

I. General information

NPI: 1174307193
Provider Name (Legal Business Name): BRIGHTWATER BEHAVIOR ANALYSIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 02/17/2024
Certification Date: 02/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4860 S PRICES PT
HOMOSASSA FL
34448-3740
US

IV. Provider business mailing address

PO BOX 584
HOMOSASSA FL
34487-0584
US

V. Phone/Fax

Practice location:
  • Phone: 352-422-5452
  • Fax:
Mailing address:
  • Phone: 352-422-5452
  • 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: JARED E MILLER
Title or Position: CEO
Credential:
Phone: 352-422-5452