Provider Demographics
NPI:1043816648
Name:COSSABOON, RICHARD JOHN
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:COSSABOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CAYLE AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-2802
Mailing Address - Country:US
Mailing Address - Phone:132-137-0663
Mailing Address - Fax:
Practice Address - Street 1:105 CAYLE AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-2802
Practice Address - Country:US
Practice Address - Phone:132-137-0663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136793106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty