=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457396574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIO-BEHAVIORAL CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 07/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11855 SW 216TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33170-2945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-601-2608
-----------------------------------------------------
Fax | 305-647-0250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 700731
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33170-0731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-601-2608
-----------------------------------------------------
Fax | 305-647-0250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LMHC, BEHAVIOR ANALYST, CEO
-----------------------------------------------------
Name | SAMIR GUSTAVO JEREZ
-----------------------------------------------------
Credential | MA, LMHC, QS
-----------------------------------------------------
Telephone | 786-601-2608
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH 5950
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------