MEDICARE: BLUE IRIS BEHAVIORAL SERVICES CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023777935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE IRIS BEHAVIORAL SERVICES CORP

Provider Business Mailing Address
First Line	:	4640 LIPSCOMB ST NE STE 4
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-2986
Country	:	US
Telephone Number	:	321-537-4467
Fax Number	:

Provider Business Practice Location Address
First Line	:	4640 LIPSCOMB ST NE STE 4
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-2986
Country	:	US
Telephone Number	:	321-537-4467
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DILIANA B POLANCO
Credential	:	LCSW
Telephone Number	:	321-537-4467

Provider Enumeration Date	:	12/08/2021
Last Update Date	:	12/08/2021

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