Provider Demographics
NPI:1750828323
Name:BEHAVIOR SERVICES OF BREVARD COUNTY
Entity Type:Organization
Organization Name:BEHAVIOR SERVICES OF BREVARD COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA-D
Authorized Official - Phone:321-639-9800
Mailing Address - Street 1:36227 E ELDORADO LAKE DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32736-9474
Mailing Address - Country:US
Mailing Address - Phone:941-357-6840
Mailing Address - Fax:
Practice Address - Street 1:550 SOLUTIONS WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3620
Practice Address - Country:US
Practice Address - Phone:321-739-9800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1041993103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS60061568500OtherDRIVER'S LICENSE NUMBER
FL1041993OtherBCBA-D CERTIFICATION NUMBER