Basic Information
| Provider Information | |||||||||
| NPI: | 1548464423 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEHAVIOR SERVICES OF BREVARD, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 SOLUTIONS WAY | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216399800 | ||||||||
| FaxNumber: | 3216396007 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 SOLUTIONS WAY | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216399800 | ||||||||
| FaxNumber: | 3216396007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 3216399800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D., LMHC, BCBA-D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | FL | N | Agencies | Day Training, Developmentally Disabled Services | 103K00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | 106S00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | 251S00000X | FL | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 675637996 | 05 | FL | MEDICAID | 003366900 | 05 | FL | MEDICAID | 675637998 | 05 | FL | MEDICAID | 003125600 | 05 | FL | MEDICAID | 017452000 | 05 | FL | MEDICAID |