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General NPI Number Information
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NPI Number | 1750107546
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Entity Type | Organization
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Legal Business Name | SMALL FOOTSTEPS LICENSED BEHAVIOR ANALYSIS PC
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Dates
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Enumeration Date | 11/26/2024
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 181 PINE TREE RD
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City | MONROE
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State | NY
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Zip | 10950-3967
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Country | US
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Telephone | 646-296-9221
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Fax |
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Provider Business Mailing Address
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Address Line | 181 PINE TREE RD
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City | MONROE
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State | NY
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Zip | 10950-3967
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Country | US
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Telephone | 646-296-9221
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Fax |
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Authorized Official
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Title or Position | LICENSED BEHAVIOR
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Name | WIDNA TAVERAS
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Credential |
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Telephone | 646-296-9221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251T00000X
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Taxonomy Name | PACE Provider Organization
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License Number |
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License Number State |
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