=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467839894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARRIE PILENZA RBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2015
-----------------------------------------------------
Last Update Date | 04/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 E MIRACLE STRIP PKWY
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-301-0438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 E MIRACLE STRIP PKWY
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-301-0438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | RBT-22-209744
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------