Basic Information
| Provider Information | |||||||||
| NPI: | 1376116772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE BEHAVIOR PLACELLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 JOHANSEN WAY | ||||||||
| Address2: | |||||||||
| City: | KINGSLAND | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315486857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5719707703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320343744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122668686 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | TREST | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4259490801 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.