MEDICARE: B&G ABA SUPPORT, LLC

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	:	1811543085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	B&G ABA SUPPORT, LLC

Provider Business Mailing Address
First Line	:	8404 WILSKY BLVD STE 105
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-1515
Country	:	US
Telephone Number	:	813-304-0777
Fax Number	:	813-433-5479

Provider Business Practice Location Address
First Line	:	8404 WILSKY BLVD STE 105
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-1515
Country	:	US
Telephone Number	:	813-304-0777
Fax Number	:	813-433-5479

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BELEN L MORALES CARVAJAL
Credential	:
Telephone Number	:	813-304-0777

Provider Enumeration Date	:	08/14/2019
Last Update Date	:	08/14/2019

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