=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689176786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLISTIC BEHAVIOR THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2018
-----------------------------------------------------
Last Update Date | 03/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1072 VISTA HAVEN CIR APT 103
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-3539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-490-7980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1072 VISTA HAVEN CIR APT 103
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-3539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-490-7980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ORLANDO MORENO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-485-5546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 16-17695
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------