1720576499 NPI number — TAYLA LOUISE PENOVICH BCBA

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 1720576499 NPI number — TAYLA LOUISE PENOVICH BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENOVICH
Provider First Name:
TAYLA
Provider Middle Name:
LOUISE
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:
VIGLIANO
Provider Other First Name:
TAYLA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720576499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1509 E COLONIAL DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32803-4729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-218-4371
Provider Business Mailing Address Fax Number:
407-218-4304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 E COLONIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32803-4510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-218-4340
Provider Business Practice Location Address Fax Number:
407-218-4303
Provider Enumeration Date:
04/27/2018

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 , with the licence number:  RBT-16-16125 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X , with the licence number: 1-19-38143 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102465000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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