Healthcare Provider Details

I. General information

NPI: 1942789516
Provider Name (Legal Business Name): SHAPING LIVES BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 S RED RD STE 208
SOUTH MIAMI FL
33143-5408
US

IV. Provider business mailing address

7742 N KENDALL DR # 422
MIAMI FL
33156-7523
US

V. Phone/Fax

Practice location:
  • Phone: 305-345-3751
  • Fax:
Mailing address:
  • Phone: 786-598-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH15356
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: CARLOS ORTIZ
Title or Position: PRESIDENT
Credential:
Phone: 305-345-3751