Provider Demographics
NPI:1245583533
Name:THE BEHAVIORAL MOM, INC
Entity Type:Organization
Organization Name:THE BEHAVIORAL MOM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KULIKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:813-260-4913
Mailing Address - Street 1:1107 CRIMSON CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-6592
Mailing Address - Country:US
Mailing Address - Phone:813-260-4913
Mailing Address - Fax:813-756-1093
Practice Address - Street 1:1107 CRIMSON CLOVER LN
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-6592
Practice Address - Country:US
Practice Address - Phone:813-260-4913
Practice Address - Fax:813-756-1093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-12-10039103K00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty