=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952549982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESPROUT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2009
-----------------------------------------------------
Last Update Date | 01/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1115 GOLDEN LAKES BLVD APT 524
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-596-8791
-----------------------------------------------------
Fax | 561-471-1332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1115 GOLDEN LAKES BLVD APT 524
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-596-8791
-----------------------------------------------------
Fax | 561-471-1332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | ROCCO L. NOCERA
-----------------------------------------------------
Credential | MA, BCBA
-----------------------------------------------------
Telephone | 561-596-8791
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-07-3256
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------