Healthcare Provider Details

I. General information

NPI: 1750058749
Provider Name (Legal Business Name): BREAKTHROUGH BEHAVIOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 W STATE ROAD 434
LONGWOOD FL
32750-5067
US

IV. Provider business mailing address

2301 MAITLAND CENTER PKWY STE 240
MAITLAND FL
32751-7415
US

V. Phone/Fax

Practice location:
  • Phone: 407-919-6845
  • Fax: 407-965-4480
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MAEGEN CHRISTINE PIERCE
Title or Position: FOUNDER CEO
Credential:
Phone: 407-574-4629