Healthcare Provider Details

I. General information

NPI: 1245583533
Provider Name (Legal Business Name): THE BEHAVIORAL MOM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 CRIMSON CLOVER LN
WESLEY CHAPEL FL
33543-6592
US

IV. Provider business mailing address

1107 CRIMSON CLOVER LN
WESLEY CHAPEL FL
33543-6592
US

V. Phone/Fax

Practice location:
  • Phone: 813-260-4913
  • Fax: 813-756-1093
Mailing address:
  • Phone: 813-260-4913
  • Fax: 813-756-1093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-10039
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateFL

VIII. Authorized Official

Name: MS. LAURA L KULIKOWSKI
Title or Position: PRESIDENT
Credential: BCBA
Phone: 813-260-4913