MEDICARE: OCEAN BLUE BEHAVIOR THERAPY INC

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	252Y00000X	Early Intervention Provider Agency
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1114790227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEAN BLUE BEHAVIOR THERAPY INC

Provider Business Mailing Address
First Line	:	4515 ASHFORD DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33880-1148
Country	:	US
Telephone Number	:	786-278-8655
Fax Number	:

Provider Business Practice Location Address
First Line	:	1137 BARTOW RD STE 207
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-5828
Country	:	US
Telephone Number	:	786-278-8655
Fax Number	:	863-583-8955

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARIA EUGENIA ACOSTA DOMINGUEZ
Credential	:	BCBA, ITDS.
Telephone Number	:	786-278-8655

Provider Enumeration Date	:	10/31/2023
Last Update Date	:	01/23/2025

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