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General NPI Number Information
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NPI Number | 1932535184
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Entity Type | Organization
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Legal Business Name | CRYSTAL LAKE SUPPORTIVE ENVIRONMENTS
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Dates
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Enumeration Date | 09/19/2013
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Last Update Date | 11/18/2013
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Provider Practice Location Address
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Address Line | 2710 STATEN AVE SUITE A
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City | ORLANDO
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State | FL
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Zip | 32804-4211
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Country | US
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Telephone | 407-965-3018
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Fax | 877-690-2003
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Provider Business Mailing Address
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Address Line | 2710 STATEN AVE SUITE A
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City | ORLANDO
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State | FL
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Zip | 32804-4211
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Country | US
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Telephone | 407-965-3018
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Fax | 877-690-2003
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. CRAIG COOK
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Credential | PH.D., BCBA-D
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Telephone | 407-965-3055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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