MEDICARE: RADIANCE BEHAVIOR THERAPY, 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	:	1114706132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANCE BEHAVIOR THERAPY, LLC

Provider Business Mailing Address
First Line	:	3901 MARY ELIZA TRCE NW STE 202
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-1096
Country	:	US
Telephone Number	:	470-615-6277
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 MARY ELIZA TRCE NW STE 202
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-1096
Country	:	US
Telephone Number	:	470-615-6277
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VICTORIA LADRONDEGUEVARA
Credential	:
Telephone Number	:	404-480-8790

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	01/10/2024

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