Provider Demographics
NPI:1144844119
Name:IMPACT BEHAVIOR SUPPORTS, INC
Entity type:Organization
Organization Name:IMPACT BEHAVIOR SUPPORTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:352-874-2986
Mailing Address - Street 1:1016 E NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5348
Mailing Address - Country:US
Mailing Address - Phone:352-874-2986
Mailing Address - Fax:
Practice Address - Street 1:1016 E NORTH BLVD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5348
Practice Address - Country:US
Practice Address - Phone:352-874-2986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health