=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538453139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNE LUIS BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2011
-----------------------------------------------------
Last Update Date | 10/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12973 SW 112 ST #151
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-5826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-558-6133
-----------------------------------------------------
Fax | 786-228-2555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12973 SW 112 ST #151
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-204-7037
-----------------------------------------------------
Fax | 786-228-2555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-17-29089
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------