MEDICARE: SUCCESS FOR KIDS 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	252Y00000X	Early Intervention Provider Agency	OT11518	FL
2	225X00000X	Occupational Therapist	OT11518	FL

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952790289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUCCESS FOR KIDS LLC

Provider Business Mailing Address
First Line	:	1636 NW 5TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-5508
Country	:	US
Telephone Number	:	954-865-3705
Fax Number	:	954-337-0141

Provider Business Practice Location Address
First Line	:	1636 NW 5TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-5508
Country	:	US
Telephone Number	:	954-865-3705
Fax Number	:	954-337-0141

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST/ OWNER
Name	:	MS. ANITA M DAVID
Credential	:	OTR
Telephone Number	:	954-865-3705

Provider Enumeration Date	:	01/09/2015
Last Update Date	:	09/09/2016

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Directions to “SUCCESS FOR KIDS LLC ” Practice Location

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