Healthcare Provider Details

I. General information

NPI: 1598571960
Provider Name (Legal Business Name): FST BEHAVIORAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

9367 TREVARTHON RD
ORLANDO FL
32817-2609
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 800-378-7597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 NICHOLAS
Title or Position: COO
Credential:
Phone: 407-530-5063