Healthcare Provider Details

I. General information

NPI: 1437978541
Provider Name (Legal Business Name): FST BEHAVIORAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N CENTRAL AVE STE 110
KISSIMMEE FL
34741-4439
US

IV. Provider business mailing address

1650 SAND LAKE RD STE 230
ORLANDO FL
32809-9138
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-5063
  • Fax: 877-399-5578
Mailing address:
  • Phone: 407-530-5063
  • Fax: 877-399-5578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: FEDERICO NICOLAS
Title or Position: COO
Credential:
Phone: 407-530-5063