Basic Information
| Provider Information | |||||||||
| NPI: | 1194328583 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOARING BEHAVIOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3637 GLEN VILLAGE CT | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328225757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865691628 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3637 GLEN VILLAGE CT | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328225757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865691628 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2020 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | MICELI | ||||||||
| AuthorizedOfficialFirstName: | TAYLOR-MARIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/FOUNDER | ||||||||
| AuthorizedOfficialTelephone: | 3865691628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 019897700 | 05 | FL | MEDICAID |