Healthcare Provider Details

I. General information

NPI: 1538986922
Provider Name (Legal Business Name): NEURODIVERGENT PARENTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

996 ROYAL MARCO WAY
MARCO ISLAND FL
34145-1829
US

IV. Provider business mailing address

996 ROYAL MARCO WAY
MARCO ISLAND FL
34145-1829
US

V. Phone/Fax

Practice location:
  • Phone: 310-699-4229
  • Fax:
Mailing address:
  • Phone: 310-699-4229
  • 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 Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: DR. THEA PHAM
Title or Position: CEO
Credential:
Phone: 310-699-4229