Basic Information
| Provider Information | |||||||||
| NPI: | 1205236130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTON | ||||||||
| FirstName: | ALEXANDER | ||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W HIBISCUS BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212654409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5163 ROSWELL RD | ||||||||
| Address2: | |||||||||
| City: | SANDY SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303422206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772884760 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2014 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-17-8064 | FL | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 106E00000X | 0-17-8064 | FL | Y |
No ID Information.