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General NPI Number Information
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NPI Number | 1639423247
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Entity Type | Organization
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Legal Business Name | SOURCE ROUTE PRODUCTS, LLC
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Dates
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Enumeration Date | 11/05/2012
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Last Update Date | 11/05/2012
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Provider Practice Location Address
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Address Line | 3795 E PARSONS POINT RD BOX 1047
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City | HERNANDO
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State | FL
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Zip | 34442-7701
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Country | US
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Telephone | 202-480-9234
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Fax |
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Provider Business Mailing Address
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Address Line | 3795 E PARSONS POINT RD BOX 1047
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City | HERNANDO
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State | FL
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Zip | 34442-7701
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. KIMBERLY MILLS
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Credential | PH.D, BCBA
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Telephone | 202-480-9234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-12-12087
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License Number State | FL
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