Healthcare Provider Details

I. General information

NPI: 1477030302
Provider Name (Legal Business Name): BENJAMIN OTWELL BS, RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 MAITLAND SUMMIT BLVD
ORLANDO FL
32810-5915
US

IV. Provider business mailing address

8701 MARYLAND SUMMIT BLVD.
ORLANDO FL
32810
US

V. Phone/Fax

Practice location:
  • Phone: 407-574-4629
  • Fax: 407-965-4480
Mailing address:
  • Phone: 407-574-4629
  • Fax: 407-965-4480

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: