=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316717275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIME TO SHINE LICENSED BEHAVIOR ANALYSIS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2024
-----------------------------------------------------
Last Update Date | 01/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 557 GRAND CONCOURSE STE 3-221
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10451-5253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-585-0713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 557 GRAND CONCOURSE STE 3-221
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10451-5253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PEARL GOLDWURM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-585-0713
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------