Provider Demographics
NPI:1902365638
Name:BEHAVIOR 180, LLC
Entity Type:Organization
Organization Name:BEHAVIOR 180, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMMESHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:TROUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:407-476-4908
Mailing Address - Street 1:420 E SR 434 STE A
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5244
Mailing Address - Country:US
Mailing Address - Phone:407-476-4908
Mailing Address - Fax:844-839-5839
Practice Address - Street 1:420 E SR 434 STE A
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5244
Practice Address - Country:US
Practice Address - Phone:407-476-4908
Practice Address - Fax:844-839-5839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017645000Medicaid