Healthcare Provider Details

I. General information

NPI: 1528601069
Provider Name (Legal Business Name): BEHAVIOR CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 SW 103RD AVE APT 304
PEMBROKE PINES FL
33025-1881
US

IV. Provider business mailing address

403 SW 103RD AVE APT 304
PEMBROKE PINES FL
33025-1881
US

V. Phone/Fax

Practice location:
  • Phone: 954-330-7611
  • Fax:
Mailing address:
  • Phone: 954-330-7611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SHAKIRA MILLAR
Title or Position: MANAGING MEMBER
Credential:
Phone: 954-330-7611