MEDICARE: FST BEHAVIORAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1023824497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FST BEHAVIORAL

Provider Business Mailing Address
First Line	:	1650 SAND LAKE RD STE 230
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-9138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4543 PLEASANT HILL RD SPC A
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34759-3406
Country	:	US
Telephone Number	:	800-378-7597
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	FEDERICO NICHOLAS
Credential	:
Telephone Number	:	407-530-5063

Provider Enumeration Date	:	12/10/2024
Last Update Date	:	12/10/2024

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