Healthcare Provider Details

I. General information

NPI: 1710538889
Provider Name (Legal Business Name): ALLIE MARIE FLY RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S BUMBY AVE
ORLANDO FL
32803-6226
US

IV. Provider business mailing address

211 S BUMBY AVE
ORLANDO FL
32803-6226
US

V. Phone/Fax

Practice location:
  • Phone: 407-801-9924
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-97505
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: