Provider Demographics
NPI:1639423247
Name:SOURCE ROUTE PRODUCTS, LLC
Entity Type:Organization
Organization Name:SOURCE ROUTE PRODUCTS, LLC
Other - Org Name:SRP, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA
Authorized Official - Phone:202-480-9234
Mailing Address - Street 1:3795 E PARSONS POINT RD
Mailing Address - Street 2:BOX 1047
Mailing Address - City:HERNANDO
Mailing Address - State:FL
Mailing Address - Zip Code:34442-7701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3795 E PARSONS POINT RD
Practice Address - Street 2:BOX 1047
Practice Address - City:HERNANDO
Practice Address - State:FL
Practice Address - Zip Code:34442-7701
Practice Address - Country:US
Practice Address - Phone:202-480-9234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-12-12087103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty