MEDICARE: PEDIATRIC BEHAVIORAL SERVICES

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	:	1144786773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC BEHAVIORAL SERVICES

Provider Business Mailing Address
First Line	:	4160 OCEANSIDE ST
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-2014
Country	:	US
Telephone Number	:	863-529-2183
Fax Number	:

Provider Business Practice Location Address
First Line	:	4160 OCEANSIDE ST
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-2014
Country	:	US
Telephone Number	:	863-529-2183
Fax Number	:

Authorized Official
Title or Position	:	BEHAVIOR ANALYST
Name	:	STACY LANDRY
Credential	:	BCBA
Telephone Number	:	863-529-2183

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	12/05/2019

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