Healthcare Provider Details

I. General information

NPI: 1689545071
Provider Name (Legal Business Name): EMERALD COAST KIDS THERAPY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4944 MULDOON POINTE RD
PENSACOLA FL
32526-1924
US

IV. Provider business mailing address

PO BOX 3523
PENSACOLA FL
32516-3523
US

V. Phone/Fax

Practice location:
  • Phone: 848-350-5973
  • Fax:
Mailing address:
  • Phone: 617-302-7272
  • 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
# 3
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name: LISA RADER
Title or Position: DIRECTOR
Credential: BCBA
Phone: 848-350-5973