=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881401958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRECER BEHAVIOR SUPPORT , LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2024
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6750 N ANDREWS AVE STE 2043
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-784-3619
-----------------------------------------------------
Fax | 813-305-7033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4307 W BIRD ST
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33614-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-454-1463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ILEANA DE CABO HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-454-1463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------