=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760085518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEADERS BEHAVIOR ABA & COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2020
-----------------------------------------------------
Last Update Date | 11/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 SW SYLVESTER LN
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34984-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-777-9265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 SW SYLVESTER LN
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34984-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-777-9265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD ANALYST
-----------------------------------------------------
Name | MS. YANED GONZALEZ
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 772-777-9265
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------