=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679334346
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RISE ABOVE BEHAVIORAL GROUP CT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2024
-----------------------------------------------------
Last Update Date | 01/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 WESTBURY PARK RD STE 306E
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-2779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-317-2818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 NE 29TH ST APT 903
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33137-5236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-235-5709
-----------------------------------------------------
Fax | 305-564-6762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BCBA
-----------------------------------------------------
Name | MRS. JENNY ACEVEDO USUGA
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 475-235-5709
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------