=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912193939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOEMIKO AMEIN FLORES BACB
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 05/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1671 GUALO RAI ROAD
-----------------------------------------------------
City | SAIPAN
-----------------------------------------------------
State | MP
-----------------------------------------------------
Zip | 96950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-294-1221
-----------------------------------------------------
Fax | 910-327-2716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 165 ALLIGATOR BAY ROAD
-----------------------------------------------------
City | SNEADS FERRY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-294-1221
-----------------------------------------------------
Fax | 910-327-2716
-----------------------------------------------------
=====================================================
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 | 0133000325
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 1-07-3519
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-07-3519
-----------------------------------------------------
License Number State |
-----------------------------------------------------