=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528672961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHA.VIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2020
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 267 LAKE DAVENPORT CIR
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33837-7527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-952-8880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 267 LAKE DAVENPORT CIR
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33837-7527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-952-8880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIOR ANALYST
-----------------------------------------------------
Name | GILLIE JOHANNA ACOSTA RIVERA
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 407-952-8880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------