NPI |
1598497463 |
The first name of the provider, if the provider
is an individual. |
Entity Type Code |
2 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Employer Identification Number EIN |
|
The city name in the location address of the provider being identified. |
Provider Organization Name Legal Business Name |
ABA ANYWHERE |
The State code in the location of the provider
being identified. |
Provider First Line Business Practice Location Address |
4837 TELLSON PL |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address City Name |
ORLANDO |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
FL |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Postal Code |
328128673 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
4079061477 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
6/28/2022 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Last Update Date |
9/6/2023 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Authorized Official Last Name |
CLARKE |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Authorized Official First Name |
ANGELIN |
The first name of the authorized official. |
Authorized Official Title or Position |
CLINICAL DIRECTOR |
The title or position of the authorized official. |
Authorized Official Telephone Number |
4079061477 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
106E00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
N |
|
Healthcare Provider Taxonomy Code 2 |
103K00000X |
|
Healthcare Provider Primary Taxonomy Switch 2 |
N |
|
Healthcare Provider Taxonomy Code 3 |
106S00000X |
|
Healthcare Provider Primary Taxonomy Switch 3 |
N |
|
Healthcare Provider Taxonomy Code 4 |
251E00000X |
|
Healthcare Provider Primary Taxonomy Switch 4 |
Y |
|
Is Organization Subpart |
N |
|
Authorized Official Credential Text |
BCBA |
|
Healthcare Provider Taxonomy Group 1 |
193400000X MULTIPLE SINGLE SPECIALTY GROUP |
|
Healthcare Provider Taxonomy Group 2 |
193400000X MULTIPLE SINGLE SPECIALTY GROUP |
|
Healthcare Provider Taxonomy Group 3 |
193400000X MULTIPLE SINGLE SPECIALTY GROUP |
|
NPI Certification Date |
9/6/2023 |
|