=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053898189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FITLIFE BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2018
-----------------------------------------------------
Last Update Date | 07/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9020 SW 137TH AVE STE 200
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-342-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9020 SW 137TH AVE STE 200
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-872-1900
-----------------------------------------------------
Fax | 786-866-2599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | NATALIE MARQUIS
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 786-872-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------