1114790227 NPI number — OCEAN BLUE BEHAVIOR THERAPY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114790227 NPI number — OCEAN BLUE BEHAVIOR THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCEAN BLUE BEHAVIOR THERAPY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114790227
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4515 ASHFORD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33880-1148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-278-8655
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1137 BARTOW RD STE 207
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33801-5828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-278-8655
Provider Business Practice Location Address Fax Number:
863-583-8955
Provider Enumeration Date:
10/31/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ACOSTA DOMINGUEZ
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
EUGENIA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
786-278-8655

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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