=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780493718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA MARIE JIMENEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2025
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 SAND LAKE RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32809-7750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-942-4461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1244 CASCADES AVE
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33837-7580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-337-1996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-24-400858
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------