=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609539675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEMIND ABA THERAGROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2021
-----------------------------------------------------
Last Update Date | 10/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 N DIXIE HWY STE 100
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-764-1554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 N DIXIE HWY STE 100
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-764-1554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MANUEL LIANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-764-1554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------