=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124988555
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSPERITY BEHAVIOR SOLUTIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2025
-----------------------------------------------------
Last Update Date | 11/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 CANFIELD DR
-----------------------------------------------------
City | MOUNT CLEMENS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48043-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-804-5282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 CANFIELD DR
-----------------------------------------------------
City | MOUNT CLEMENS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48043-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-804-5282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAYDE PETERS
-----------------------------------------------------
Credential | BCBA, LBA
-----------------------------------------------------
Telephone | 586-804-5282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------