1669858221 NPI number — NATASHA SHUNTAY BOGES BCBA

Table of content: NATASHA SHUNTAY BOGES BCBA (NPI 1669858221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669858221 NPI number — NATASHA SHUNTAY BOGES BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOGES
Provider First Name:
NATASHA
Provider Middle Name:
SHUNTAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

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:
1669858221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 INTERNATIONAL PKWY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-5028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-610-0580
Provider Business Mailing Address Fax Number:
866-610-0580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17435 US HIGHWAY 441 STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT DORA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32757-6750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-434-0455
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

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

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

  • Identifier: 019328300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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