1275257073 NPI number — PROGRESSIVE BEHAVIOR THERAPY INC

Table of content: MRS. CANDICE LYNN WILSON M.S. CCC SLP (NPI 1326257189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275257073 NPI number — PROGRESSIVE BEHAVIOR THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE 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:
1275257073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8960 SW HIGHWAY 200 STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34481-1700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-718-9599
Provider Business Mailing Address Fax Number:
877-388-1240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8960 SW HIGHWAY 200 STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34481-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-718-9599
Provider Business Practice Location Address Fax Number:
877-388-1240
Provider Enumeration Date:
09/27/2022

Additional Information

Authorized Official

Authorized Official Last Name:
RYCHKO
Authorized Official First Name:
IRYNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
786-718-9599

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: 113842500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com