MEDICARE: PROFESSIONAL BEHAVIOR THERAPY CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1134709579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL BEHAVIOR THERAPY CORP

Provider Business Mailing Address
First Line	:	16536 SW 85TH LN
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33193-5794
Country	:	US
Telephone Number	:	305-877-3886
Fax Number	:

Provider Business Practice Location Address
First Line	:	16536 SW 85TH LN
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33193-5794
Country	:	US
Telephone Number	:	305-877-3886
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ADRIA GONZALEZ
Credential	:	BCBA
Telephone Number	:	305-877-3886

Provider Enumeration Date	:	04/09/2021
Last Update Date	:	08/20/2021

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