=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063785970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIOR ANALYTIC SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2012
-----------------------------------------------------
Last Update Date | 02/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3340 LAKE JEAN DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-2326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-286-2533
-----------------------------------------------------
Fax | 407-679-8818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3340 LAKE JEAN DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-2326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-286-2533
-----------------------------------------------------
Fax | 407-679-8818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. SHAVETA SURI
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 407-286-2533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-09-6568
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------