Healthcare Provider Details

I. General information

NPI: 1114790227
Provider Name (Legal Business Name): OCEAN BLUE BEHAVIOR THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 BARTOW RD STE 207
LAKELAND FL
33801-5828
US

IV. Provider business mailing address

4515 ASHFORD DR
WINTER HAVEN FL
33880-1148
US

V. Phone/Fax

Practice location:
  • Phone: 786-278-8655
  • Fax: 863-583-8955
Mailing address:
  • Phone: 786-278-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIA EUGENIA ACOSTA DOMINGUEZ
Title or Position: OWNER
Credential: BCBA, ITDS.
Phone: 786-278-8655