Healthcare Provider Details

I. General information

NPI: 1265091441
Provider Name (Legal Business Name): LAUREN ASHLEY PETERSON M.A., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN ASHLEY VIDAL M.A., BCBA

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6421 N FLORIDA AVE SUITE D-1458
TAMPA FL
33604-6007
US

IV. Provider business mailing address

7108 S KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 855-832-6727
  • Fax: 772-675-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-50373
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: