Healthcare Provider Details

I. General information

NPI: 1093310393
Provider Name (Legal Business Name): OWL BEHAVIOR ANALYSIS PRACTICE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 08/21/2024
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18245 PAULSON DR. SUITE 104
PORT CHARLOTTE FL
33954-1019
US

IV. Provider business mailing address

18245 PAULSON DR. SUITE 104
PORT CHARLOTTE FL
33954-1019
US

V. Phone/Fax

Practice location:
  • Phone: 813-528-7048
  • Fax: 855-610-2343
Mailing address:
  • Phone: 813-528-7048
  • Fax: 855-610-2343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MRS. JACQUELINE ESTRADA LOPEZ
Title or Position: PRESIDENT
Credential: BCBA
Phone: 813-528-7048