Healthcare Provider Details

I. General information

NPI: 1013530096
Provider Name (Legal Business Name): KIDS BEHAVIORAL NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209A N EAST ST # 211
FREDERICK MD
21701-4624
US

IV. Provider business mailing address

11390 SW 21ST ST
MIRAMAR FL
33025-6633
US

V. Phone/Fax

Practice location:
  • Phone: 786-333-2975
  • Fax:
Mailing address:
  • Phone: 786-333-9275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MISS JENNY COELLO
Title or Position: CEO
Credential: M.S., LMHC, BCBA
Phone: 786-333-2975