=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275275976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST BEHAVIOR THERAPY GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2022
-----------------------------------------------------
Last Update Date | 04/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4160 W 16TH AVE STE 504-505
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-5830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-896-4251
-----------------------------------------------------
Fax | 305-640-5469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4160 W 16TH AVE STE 504-505
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-5830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-896-4251
-----------------------------------------------------
Fax | 305-640-5469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | YANEPSY SANTOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-896-4251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------