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General NPI Number Information
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NPI Number | 1184537243
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Entity Type | Organization
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Legal Business Name | LYZA AND M'LEEYA PLAYHOUSE
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Dates
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Enumeration Date | 09/28/2026
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Last Update Date | 09/30/2026
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Provider Practice Location Address
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Address Line | 1556 S PARK AVE
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City | TITUSVILLE
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State | FL
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Zip | 32780-4364
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Country | US
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Telephone | 407-802-7071
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Fax |
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Provider Business Mailing Address
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Address Line | 1556 S PARK AVE
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City | TITUSVILLE
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State | FL
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Zip | 32780-4364
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Country | US
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Telephone | 407-802-7071
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JASMINE POUGH
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Credential |
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Telephone | 407-802-7071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP1600X
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Taxonomy Name | Pastoral Counselor
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License Number |
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License Number State | NULL
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Taxonomy #2
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State | NULL
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