=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871121202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEVEN RENAE VANTREASE BCBA, LBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2020
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 159 DOUGHTY BLVD
-----------------------------------------------------
City | INWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-886-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6602 BOAT RACE RD
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32404-9616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-890-3936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 12369331
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------