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General NPI Number Information
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NPI Number | 1881131753
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Entity Type | Organization
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Legal Business Name | SELENA ROE
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Dates
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Enumeration Date | 01/30/2017
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Last Update Date | 02/01/2017
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Provider Practice Location Address
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Address Line | 2545 NE COACHMAN RD APT 150
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City | CLEARWATER
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State | FL
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Zip | 33765-1810
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Country | US
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Telephone | 727-687-9261
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Fax |
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Provider Business Mailing Address
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Address Line | 2600 MARTIN LUTHER KING ST N STE 401
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City | ST PETERSBURG
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State | FL
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Zip | 33704-2744
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Country | US
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Telephone | 727-327-2457
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Fax |
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Authorized Official
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Title or Position | BEHAVIOR ANALYST/ OWNER
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Name | MRS. SELENA ROE, JORDAN
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Credential | BCBA
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Telephone | 727-327-2457
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | BACB268792
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License Number State | FL
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