=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366961617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTHA RADON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2017
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18288 N US HIGHWAY 41
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33549-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-527-9963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 REVERE DR STE 120
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-8005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-356-4049
-----------------------------------------------------
Fax | 941-485-0519
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-20-145578
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-24-77533
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------