Healthcare Provider Details

I. General information

NPI: 1770499204
Provider Name (Legal Business Name): EMERFORM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 DELANEY AVE APT D14
ORLANDO FL
32806-1202
US

IV. Provider business mailing address

1100 DELANEY AVE APT D14
ORLANDO FL
32806-1202
US

V. Phone/Fax

Practice location:
  • Phone: 407-433-6264
  • 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: ANGELINE BENNETT
Title or Position: OWNER/OPERATOR
Credential: BCBA
Phone: 407-433-6264