Provider Demographics
NPI:1336418417
Name:PROGRESSIVE BEHAVIOR MANAGEMENT RES, INC.
Entity Type:Organization
Organization Name:PROGRESSIVE BEHAVIOR MANAGEMENT RES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BCBA
Authorized Official - Prefix:MS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:SPARKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:813-525-5468
Mailing Address - Street 1:220 W BRANDON BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5104
Mailing Address - Country:US
Mailing Address - Phone:813-525-5468
Mailing Address - Fax:813-438-8903
Practice Address - Street 1:628 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8111
Practice Address - Country:US
Practice Address - Phone:813-525-5468
Practice Address - Fax:813-438-8903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-07-3280103K00000X
FLOT 11898225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty