=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609374578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMA BEHAVIORAL CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2018
-----------------------------------------------------
Last Update Date | 01/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 339 SUMMER SAILS DR
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33594-8011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-406-9336
-----------------------------------------------------
Fax | 813-252-1370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 339 SUMMER SAILS DR
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33594-8011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-406-9336
-----------------------------------------------------
Fax | 813-252-1370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISS AMARILYS MORALES
-----------------------------------------------------
Credential | M.S., BCBA
-----------------------------------------------------
Telephone | 813-406-9336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-16-24898
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------