Healthcare Provider Details

I. General information

NPI: 1487024535
Provider Name (Legal Business Name): FAMILY BEHAVIORAL SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12665 WHITE CEDAR TRL
JACKSONVILLE FL
32226-5032
US

IV. Provider business mailing address

12665 WHITE CEDAR TRL
JACKSONVILLE FL
32226-5032
US

V. Phone/Fax

Practice location:
  • Phone: 904-535-0660
  • Fax:
Mailing address:
  • Phone: 904-535-0660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-5608
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-13-5622
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-15-02211
License Number StateFL

VIII. Authorized Official

Name: KRISTEN DUFFNEY
Title or Position: PRESIDENT
Credential: MS, BCBA
Phone: 904-535-0660