Healthcare Provider Details

I. General information

NPI: 1053066845
Provider Name (Legal Business Name): MY INNOVATIVE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2022
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17820 NW 48TH COURT
MIAMI GARDENS FL
33055
US

IV. Provider business mailing address

17820 NW 48TH CT
MIAMI GARDENS FL
33055-3210
US

V. Phone/Fax

Practice location:
  • Phone: 855-316-1125
  • Fax:
Mailing address:
  • Phone: 855-316-1125
  • 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
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANNELISA MARISOL MACHADO
Title or Position: OWNER
Credential: BCBA
Phone: 855-316-1125