Provider Demographics
NPI:1407592900
Name:CLUB SPECTRUM ABA
Entity Type:Organization
Organization Name:CLUB SPECTRUM ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER CEO
Authorized Official - Prefix:
Authorized Official - First Name:CORI-ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BONFILIO
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:407-369-3788
Mailing Address - Street 1:3700 CURRY FORD RD APT M8
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2641
Mailing Address - Country:US
Mailing Address - Phone:407-369-3788
Mailing Address - Fax:
Practice Address - Street 1:3700 CURRY FORD RD APT M8
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2641
Practice Address - Country:US
Practice Address - Phone:407-369-3788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-08
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health