Healthcare Provider Details

I. General information

NPI: 1700798634
Provider Name (Legal Business Name): FULLSPECTRUMABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 BEATY GROVE DR
TAMPA FL
33626-1602
US

IV. Provider business mailing address

41 ROSS HALL RD
PRENTISS MS
39474-2999
US

V. Phone/Fax

Practice location:
  • Phone: 813-926-5454
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KATRINA CHEATHAM
Title or Position: BEHAVIOR TECH
Credential:
Phone: 601-325-6063