=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700679800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN AUTISM CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2025
-----------------------------------------------------
Last Update Date | 05/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3884 BANNOCK AVE
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-9201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-569-1112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3884 BANNOCK AVE
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-9201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-569-1112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BCBA
-----------------------------------------------------
Name | MISS ANNE FLETCHER
-----------------------------------------------------
Credential | M.ED., BCBA
-----------------------------------------------------
Telephone | 315-569-1112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------