=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659121994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF BREEZE BEHAVIOR ANALYTIC SERVICES AND CONSULTATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2024
-----------------------------------------------------
Last Update Date | 03/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8721 SAN PABLO AVE
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34287-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-626-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7393
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34290-0393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 941-564-7671
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD ANALYST
-----------------------------------------------------
Name | MRS. CHELSEA SUZANNE PLANTZ
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 941-626-6644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------