Provider Demographics
NPI:1861821084
Name:FIRST COAST AUTISM LLC
Entity Type:Organization
Organization Name:FIRST COAST AUTISM LLC
Other - Org Name:DAVID CALABRESE, BCBA, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BEHAVIOR ANALYST/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CALABRESE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:386-227-6485
Mailing Address - Street 1:8 WILDWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137
Mailing Address - Country:US
Mailing Address - Phone:386-227-6485
Mailing Address - Fax:866-247-1790
Practice Address - Street 1:8 WILDWOOD LANE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137
Practice Address - Country:US
Practice Address - Phone:386-227-6485
Practice Address - Fax:866-247-1790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106E00000X, 106S00000X
FL1-12-11985251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021072800Medicaid