Healthcare Provider Details

I. General information

NPI: 1124583216
Provider Name (Legal Business Name): DIANA MACCHIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 NE ELDERBERRY TER
JENSEN BEACH FL
34957-4655
US

IV. Provider business mailing address

85 NE ELDERBERRY TER
JENSEN BEACH FL
34957-4655
US

V. Phone/Fax

Practice location:
  • Phone: 914-494-0628
  • Fax:
Mailing address:
  • Phone: 914-494-0628
  • 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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DIANA MACCHIA
Title or Position: OWNER
Credential: MS, BCBA
Phone: 914-494-0628