Provider Demographics
NPI:1144786773
Name:PEDIATRIC BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:PEDIATRIC BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:863-529-2183
Mailing Address - Street 1:4160 OCEANSIDE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-2014
Mailing Address - Country:US
Mailing Address - Phone:863-529-2183
Mailing Address - Fax:
Practice Address - Street 1:4160 OCEANSIDE ST
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34286-2014
Practice Address - Country:US
Practice Address - Phone:863-529-2183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-19
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty