Provider Demographics
NPI:1679114920
Name:JUDD, SAMUEL (BCBA)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:JUDD
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14714 VISTA DEL LAGO BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8803
Mailing Address - Country:US
Mailing Address - Phone:304-707-5510
Mailing Address - Fax:
Practice Address - Street 1:601 S LAKE DESTINY RD STE 350
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7222
Practice Address - Country:US
Practice Address - Phone:407-647-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-23-14623106E00000X
FL1-24-71059103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-24-71059OtherBACB
FL102795100Medicaid