Provider Demographics
NPI:1770825028
Name:PAVICH, HEATHER MARIE (MED BCBA)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MARIE
Last Name:PAVICH
Suffix:
Gender:F
Credentials:MED BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 S SAINT LUCIE DR
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5534
Mailing Address - Country:US
Mailing Address - Phone:321-277-2664
Mailing Address - Fax:
Practice Address - Street 1:3617 S SAINT LUCIE DR
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5534
Practice Address - Country:US
Practice Address - Phone:321-277-2664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11312967103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst