MEDICARE: CREATING A DIFFERENCE 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	1-17-27747	FL
2	261QD1600X	Developmental Disabilities Clinic/Center
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center
4	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-17-27747	OTHER	FL	CERTIFICATION NUMBER FOR BCBA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104332394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATING A DIFFERENCE LLC

Provider Business Mailing Address
First Line	:	43 S POWERLINE RD # 248
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33069-3001
Country	:	US
Telephone Number	:	786-301-7622
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 CYPRESS BLVD APT 204
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33069-4078
Country	:	US
Telephone Number	:	786-301-7622
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DIANA BENCID
Credential	:	MS, BCBA
Telephone Number	:	786-301-7622

Provider Enumeration Date	:	12/26/2017
Last Update Date	:	12/27/2017

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Directions to “CREATING A DIFFERENCE LLC ” Practice Location

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