Provider Demographics
NPI:1073960993
Name:INTENSIVE BEHAVIOR SUPPORTS
Entity Type:Organization
Organization Name:INTENSIVE BEHAVIOR SUPPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NENNI
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:727-744-9829
Mailing Address - Street 1:90 CITRUS CT
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-3702
Mailing Address - Country:US
Mailing Address - Phone:727-744-9829
Mailing Address - Fax:
Practice Address - Street 1:90 CITRUS CT
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-3702
Practice Address - Country:US
Practice Address - Phone:727-744-9829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1000169103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011132200OtherMEDICAID WAIVER