Provider Demographics
NPI:1649667270
Name:LAXTON, TARA (BCBA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LAXTON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:TORTORELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3327 TUSCANO AVE
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-4665
Mailing Address - Country:US
Mailing Address - Phone:609-707-4863
Mailing Address - Fax:
Practice Address - Street 1:1176 PELICAN BAY DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-1381
Practice Address - Country:US
Practice Address - Phone:386-767-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-14-16194103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst