=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366991416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BASIC LIFE SUPPORT THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2016
-----------------------------------------------------
Last Update Date | 09/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3561 POWERLINE RD
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309-5928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-579-9935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3561 POWERLINE RD
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309-5928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-579-9935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADM
-----------------------------------------------------
Name | KATHERINE MAUGHN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-579-9935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 4015A
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | 1216
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1380
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------