=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871917005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIOR CHANGES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2014
-----------------------------------------------------
Last Update Date | 02/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2918 GLENN ST
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32563-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-343-2010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2918 GLENN ST
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32563-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-343-2010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | STEVEN C STOUT
-----------------------------------------------------
Credential | PH.D., BCBA-D
-----------------------------------------------------
Telephone | 256-343-2010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------