=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922758804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH FLORIDA BEHAVIORAL CONSULTANTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2022
-----------------------------------------------------
Last Update Date | 03/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 462 AQUATIC DR
-----------------------------------------------------
City | ATLANTIC BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32233-3834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-252-0427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 462 AQUATIC DR
-----------------------------------------------------
City | ATLANTIC BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32233-3834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-252-0427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. CLIFFORD CHARLES BURDITT JR.
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 904-252-0427
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------