=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437860673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIVOTAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2022
-----------------------------------------------------
Last Update Date | 08/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7721 SW 62ND AVE STE 203
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-4907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-707-1600
-----------------------------------------------------
Fax | 888-810-9374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7721 SW 62ND AVE STE 203
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-4907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-707-1600
-----------------------------------------------------
Fax | 888-810-9374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMERICA CONDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-878-6913
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------