Healthcare Provider Details

I. General information

NPI: 1588546584
Provider Name (Legal Business Name): HEATHER E PELTACK BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 13TH AVE S STE 270
JACKSONVILLE BEACH FL
32250-3258
US

IV. Provider business mailing address

PO BOX 748519
ATLANTA GA
30374-8519
US

V. Phone/Fax

Practice location:
  • Phone: 904-376-3800
  • Fax: 904-390-7394
Mailing address:
  • Phone: 904-376-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-15-18937
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: