=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821520503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MBKNOWLES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2017
-----------------------------------------------------
Last Update Date | 03/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2065 SE LENNARD RD APT 307
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-4753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-284-1873
-----------------------------------------------------
Fax | 772-207-5808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2065 SE LENNARD RD APT 307
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-284-1873
-----------------------------------------------------
Fax | 772-207-5808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIOR TECHNICIAN
-----------------------------------------------------
Name | MADISON BRITTANY KNOWLES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-284-1873
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------