Healthcare Provider Details

I. General information

NPI: 1285239632
Provider Name (Legal Business Name): MICAH COURSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1160 S SEMORAN BLVD
ORLANDO FL
32807-1461
US

IV. Provider business mailing address

1160 S SEMORAN BLVD
ORLANDO FL
32807-1461
US

V. Phone/Fax

Practice location:
  • Phone: 800-676-5130
  • Fax: 888-959-5753
Mailing address:
  • Phone: 800-676-5130
  • Fax: 888-959-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: