Healthcare Provider Details

I. General information

NPI: 1578282059
Provider Name (Legal Business Name): SUPPORT THERAPY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 AIRFIELD DR E STE 202 SUITE 202
LAKELAND FL
33811-1247
US

IV. Provider business mailing address

3240 AIRFIELD DR E STE 202
LAKELAND FL
33811-1247
US

V. Phone/Fax

Practice location:
  • Phone: 646-966-2583
  • Fax: 407-386-6505
Mailing address:
  • Phone: 646-966-2583
  • Fax: 407-386-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: ISMERY D MORALES MARTINEZ
Title or Position: MANAGER
Credential: SLP/BCBA
Phone: 407-486-3297