Healthcare Provider Details

I. General information

NPI: 1750107546
Provider Name (Legal Business Name): SMALL FOOTSTEPS LICENSED BEHAVIOR ANALYSIS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 PINE TREE RD
MONROE NY
10950-3967
US

IV. Provider business mailing address

181 PINE TREE RD
MONROE NY
10950-3967
US

V. Phone/Fax

Practice location:
  • Phone: 646-296-9221
  • Fax:
Mailing address:
  • Phone: 646-296-9221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: WIDNA TAVERAS
Title or Position: LICENSED BEHAVIOR
Credential:
Phone: 646-296-9221