MEDICARE: BRILLIANT BLUE BEHAVIOR ANALYSIS LLC

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

General Provider Information

NPI Number	:	1083314652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRILLIANT BLUE BEHAVIOR ANALYSIS LLC

Provider Business Mailing Address
First Line	:	13100 SW 262ND LN
Second Line	:
City	:	HOMESTEAD
State	:	FL
Zip	:	33032-8924
Country	:	US
Telephone Number	:	786-404-3114
Fax Number	:	786-404-3124

Provider Business Practice Location Address
First Line	:	11285 SW 211TH ST STE 203
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33189-2213
Country	:	US
Telephone Number	:	786-404-3114
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VIVIANA FERNANDEZ
Credential	:
Telephone Number	:	786-509-3700

Provider Enumeration Date	:	03/03/2023
Last Update Date	:	08/28/2025

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