=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881982759
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAMELA D LIVELY BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2011
-----------------------------------------------------
Last Update Date | 07/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3543 BARREL SPRINGS DR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-2238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-517-2010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3543 BARREL SPRINGS DR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-2238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-683-6206
-----------------------------------------------------
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 | 1-10-7896
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------