Healthcare Provider Details

I. General information

NPI: 1104332394
Provider Name (Legal Business Name): CREATING A DIFFERENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2017
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CYPRESS BLVD APT 204
POMPANO BEACH FL
33069-4078
US

IV. Provider business mailing address

43 S POWERLINE RD # 248
POMPANO BEACH FL
33069-3001
US

V. Phone/Fax

Practice location:
  • Phone: 786-301-7622
  • Fax:
Mailing address:
  • Phone: 786-301-7622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-27747
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANA BENCID
Title or Position: SOLE MEMBER
Credential: MS, BCBA
Phone: 786-301-7622