MEDICARE: BLUEBIRD THERAPY CENTER, LLC

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

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	:	1932824224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBIRD THERAPY CENTER, LLC

Provider Business Mailing Address
First Line	:	200 LESLIE DR APT 429
Second Line	:
City	:	HALLANDALE BEACH
State	:	FL
Zip	:	33009-7314
Country	:	US
Telephone Number	:	954-805-2559
Fax Number	:

Provider Business Practice Location Address
First Line	:	5206 HALIFAX DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-4631
Country	:	US
Telephone Number	:	954-805-2559
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DIANE DONIS
Credential	:
Telephone Number	:	954-805-2559

Provider Enumeration Date	:	10/10/2022
Last Update Date	:	10/10/2022

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