=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194128959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI SUGAR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 04/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 SE 19TH AVE
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33060-7543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 549-774-0469
-----------------------------------------------------
Fax | 549-941-1164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 SE 19TH AVE
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33060-7543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 549-774-0469
-----------------------------------------------------
Fax | 549-941-1164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-15-19220
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------