Provider Demographics
NPI:1912695495
Name:PEARSON, MICHELLE AUTUMN (BCBA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:AUTUMN
Last Name:PEARSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12586 JAYBIRD RD
Mailing Address - Street 2:
Mailing Address - City:WEEKI WACHEE
Mailing Address - State:FL
Mailing Address - Zip Code:34614-3267
Mailing Address - Country:US
Mailing Address - Phone:352-556-7113
Mailing Address - Fax:
Practice Address - Street 1:4553 GRAND BLVD STE 206
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-5157
Practice Address - Country:US
Practice Address - Phone:727-534-3234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12258592103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst