Basic Information
| Provider Information | |||||||||
| NPI: | 1467810184 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRILLIANT CONCEPTS BEHAVIORAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1557 PINE MARSH LOOP | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347717407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072424320 | ||||||||
| FaxNumber: | 4079603009 | ||||||||
| Practice Location | |||||||||
| Address1: | 1557 PINE MARSH LOOP | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347717407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072424320 | ||||||||
| FaxNumber: | 4079603009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2016 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | ZEBALLOS | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4072424320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BCBA-D | ||||||||
| NPICertificationDate: | |||||||||
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.