Healthcare Provider Details

I. General information

NPI: 1962886044
Provider Name (Legal Business Name): BEHAVIOR & COGNITIVE THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 6TH AVE
INDIALANTIC FL
32903-3303
US

IV. Provider business mailing address

201 6TH AVE
INDIALANTIC FL
32903-3303
US

V. Phone/Fax

Practice location:
  • Phone: 321-544-4351
  • Fax: 321-775-3484
Mailing address:
  • Phone: 321-544-4351
  • Fax: 321-775-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH7350
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-00-0132
License Number StateFL

VIII. Authorized Official

Name: DR. SUSAN MARIE JENNINGS
Title or Position: PRESIDENT
Credential: ED. D, LMHC, BCBA-D
Phone: 321-544-4351