=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528691649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACE BEHAVIOR ALLIANCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2020
-----------------------------------------------------
Last Update Date | 02/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13645 E COLONIAL DR APT D390
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32826-4931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-388-8188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1969 S ALAFAYA TRL # 346
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32828-8732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-388-8188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LESLIE SELINA SANDOVAL
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 407-931-6212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------