MEDICARE: MY DEVELOPMENTAL THERAPY. INC

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	222Q00000X	Developmental Therapist
2	252Y00000X	Early Intervention Provider Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841864501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY DEVELOPMENTAL THERAPY. INC

Provider Business Mailing Address
First Line	:	1011 FAIRFIELD MEADOWS DR
Second Line	:
City	:	WESTON
State	:	FL
Zip	:	33327-1822
Country	:	US
Telephone Number	:	954-470-0771
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 FAIRFIELD MEADOWS DR
Second Line	:
City	:	WESTON
State	:	FL
Zip	:	33327-1822
Country	:	US
Telephone Number	:	954-470-0771
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. ALEJANDRA GUTIERREZ
Credential	:
Telephone Number	:	954-470-0771

Provider Enumeration Date	:	05/18/2021
Last Update Date	:	12/03/2021

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