Healthcare Provider Details

I. General information

NPI: 1972878437
Provider Name (Legal Business Name): PROVIDENCE ACADEMY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 S ALAFAYA TRL SUITE 200
ORLANDO FL
32828-8956
US

IV. Provider business mailing address

1561 S ALAFAYA TRL SUITE 200
ORLANDO FL
32828-8956
US

V. Phone/Fax

Practice location:
  • Phone: 407-382-5551
  • Fax: 407-382-5637
Mailing address:
  • Phone: 407-382-5551
  • Fax: 407-382-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALICIA NARET BRACCIA
Title or Position: FOUNDATION PRESIDENT
Credential: MA,CAS,ABSNP, LSP
Phone: 407-382-5551