Provider Demographics
NPI:1396017414
Name:SOUTHLAKE AUTISM AND BEHAVIOR SERVICES, PA
Entity Type:Organization
Organization Name:SOUTHLAKE AUTISM AND BEHAVIOR SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/BEHAVIOR ANALYST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:352-223-1999
Mailing Address - Street 1:13201 SUGARBLUFF RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34715-6819
Mailing Address - Country:US
Mailing Address - Phone:352-978-5903
Mailing Address - Fax:352-600-3119
Practice Address - Street 1:350 ACCEPTANCE WAY
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-223-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-11-4087251B00000X, 251C00000X, 251S00000X, 252Y00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care