=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396402335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKYROCKET BEHAVIORAL SERVICES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2021
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7376 LAKE WORTH RD
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33467-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-788-4086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7376 LAKE WORTH RD
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33467-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-788-4086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FABIANA GOMEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-475-6308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106E00000X
-----------------------------------------------------
Taxonomy Name | Assistant Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------