=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164030904
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL MACK BCBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2020
-----------------------------------------------------
Last Update Date | 02/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1170 CELEBRATION BLVD
-----------------------------------------------------
City | CELEBRATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34747-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-966-3070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2047 LIMESTONE TRL
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34747-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-869-2423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-20-131232
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | BACB-1-25-86656
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------