Healthcare Provider Details

I. General information

NPI: 1902365638
Provider Name (Legal Business Name): BEHAVIOR 180, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E SR 434 STE A
LONGWOOD FL
32750-5244
US

IV. Provider business mailing address

420 E SR 434 STE A
LONGWOOD FL
32750-5244
US

V. Phone/Fax

Practice location:
  • Phone: 407-476-4908
  • Fax: 844-839-5839
Mailing address:
  • Phone: 407-476-4908
  • Fax: 844-839-5839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: KIMMESHA C TROUTMAN
Title or Position: OWNER
Credential: M.A., BCBA
Phone: 407-476-4908