=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023512076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST APPLIED BEHAVIORAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2018
-----------------------------------------------------
Last Update Date | 03/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12907 BLISS LOOP
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-229-1029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 110374
-----------------------------------------------------
City | LAKEWOOD RCH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-0005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-229-1029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED MEMBER
-----------------------------------------------------
Name | MRS. LIDIA MONTERO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-229-1029
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------