Basic Information
| Provider Information | |||||||||
| NPI: | 1760923437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEHAVIOR MODIFICATION SOLUTIONS ABA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ON EAGLES WINGS ABA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1941 CRAPE MYRTLE LOOP APT 205 | ||||||||
| Address2: | 205 | ||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335494008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564548539 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1941 CRAPE MYRTLE LOOP | ||||||||
| Address2: | 205 | ||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564548539 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2017 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | PEARSON | ||||||||
| AuthorizedOfficialMiddleName: | FOSS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9564548539 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-12-10524 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 017539500 | 05 | FL | MEDICAID |