Basic Information
Provider Information | |||||||||
NPI: | 1922663566 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | POSITIVE BEHAVIOR SUPPORTS CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7108 S KANNER HWY | ||||||||
Address2: |   | ||||||||
City: | STUART | ||||||||
State: | FL | ||||||||
PostalCode: | 349977462 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8558326727 | ||||||||
FaxNumber: | 7726759100 | ||||||||
Practice Location | |||||||||
Address1: | 7108 S KANNER HWY | ||||||||
Address2: |   | ||||||||
City: | STUART | ||||||||
State: | FL | ||||||||
PostalCode: | 349977462 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8558326727 | ||||||||
FaxNumber: | 7726759100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2019 | ||||||||
LastUpdateDate: | 05/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FERNANDEZ MIRANDA | ||||||||
AuthorizedOfficialFirstName: | YANET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | RBT | ||||||||
AuthorizedOfficialTelephone: | 5616330307 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.