Healthcare Provider Details

I. General information

NPI: 1538824545
Provider Name (Legal Business Name): EARLY INTERVENTION PROGRAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 NW 82ND AVE STE N
DORAL FL
33166-6652
US

IV. Provider business mailing address

3625 NW 82ND AVE STE ZZ
DORAL FL
33166-6652
US

V. Phone/Fax

Practice location:
  • Phone: 786-615-2890
  • Fax: 305-381-5119
Mailing address:
  • Phone: 786-643-7819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: ANGELA TEJEDA
Title or Position: CEO
Credential:
Phone: 786-643-7819