Healthcare Provider Details

I. General information

NPI: 1154600419
Provider Name (Legal Business Name): CLIFFORD C BURDITT JR. BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4624 PARK ST
JACKSONVILLE FL
32205-7327
US

IV. Provider business mailing address

4624 PARK ST
JACKSONVILLE FL
32205-7327
US

V. Phone/Fax

Practice location:
  • Phone: 904-503-0131
  • Fax: 636-600-2012
Mailing address:
  • Phone: 904-503-0131
  • Fax: 904-636-2012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-25857
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: