Healthcare Provider Details

I. General information

NPI: 1356998637
Provider Name (Legal Business Name): ADVANCED CHILDRENS THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 02/26/2023
Certification Date: 02/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2119 10TH AVE N
LAKE WORTH BEACH FL
33461-3345
US

IV. Provider business mailing address

2119 10TH AVE N
LAKE WORTH BEACH FL
33461-3345
US

V. Phone/Fax

Practice location:
  • Phone: 561-629-6882
  • Fax: 561-828-3102
Mailing address:
  • Phone: 561-629-6882
  • Fax: 561-828-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARLYE GONZALEZ ALFONSO
Title or Position: ADMINISTRATOR
Credential:
Phone: 561-260-1316