Healthcare Provider Details

I. General information

NPI: 1992182760
Provider Name (Legal Business Name): LORIANN SAMANTHA DEMELLO BCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 FOREST HILL BLVD
LAKE CLARKE SHORES FL
33406
US

IV. Provider business mailing address

1815 FOREST HILL BLVD
LAKE CLARKE SHORES FL
33406-6021
US

V. Phone/Fax

Practice location:
  • Phone: 561-360-3169
  • Fax:
Mailing address:
  • Phone: 561-360-3169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0145945
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-14-5945
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: