=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720798069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGICAL DREAMS ACADEMY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2022
-----------------------------------------------------
Last Update Date | 01/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 966 SW 82ND AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-4271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-335-9627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 966 SW 82ND AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-4271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-335-9627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / ADMINISTRATOR
-----------------------------------------------------
Name | MR. LUIS LEDESMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-335-9627
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------