=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912338443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RESA DEMINT B.S. BCABA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2013
-----------------------------------------------------
Last Update Date | 12/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8016 ATLANTIC BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32211-8751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-329-3317
-----------------------------------------------------
Fax | 904-329-3318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4850 ASHLEY MANOR WAY W
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32225-4039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-519-4804
-----------------------------------------------------
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 | 0-13-5622
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------