1568130136 NPI number — BREAKTHROUGH BEHAVIOR LLC

Table of content: (NPI 1568130136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568130136 NPI number — BREAKTHROUGH BEHAVIOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREAKTHROUGH BEHAVIOR LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568130136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 MAITLAND CENTER PKWY STE 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10817 BLOOMINGDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33578-3616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-324-1342
Provider Business Practice Location Address Fax Number:
407-965-4480
Provider Enumeration Date:
08/31/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PIERCE
Authorized Official First Name:
MAEGEN
Authorized Official Middle Name:
CHRISTINE
Authorized Official Title or Position:
FOUNDER CEO
Authorized Official Telephone Number:
407-574-4629

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 107474804 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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