Healthcare Provider Details

I. General information

NPI: 1285239590
Provider Name (Legal Business Name): GULFPORT PREMIER ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 COURTHOUSE RD UNIT 3
GULFPORT MS
39507-4110
US

IV. Provider business mailing address

928 COURTHOUSE RD UNIT 3
GULFPORT MS
39507-4110
US

V. Phone/Fax

Practice location:
  • Phone: 228-229-8297
  • Fax:
Mailing address:
  • Phone: 228-229-8297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY STANFORD
Title or Position: CO-OWNER
Credential: BCBS, LBA
Phone: 228-229-8297