MEDICARE: LITTLE VICTORIES, 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	1-14-17062

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	:	1205321890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE VICTORIES, LLC

Provider Business Mailing Address
First Line	:	222 SEMINOLE LAKES DR
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-4207
Country	:	US
Telephone Number	:	561-843-9060
Fax Number	:

Provider Business Practice Location Address
First Line	:	222 SEMINOLE LAKES DR
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-4207
Country	:	US
Telephone Number	:	561-843-9060
Fax Number	:

Authorized Official
Title or Position	:	BCBA
Name	:	CHASITY EVANS
Credential	:	BCBA
Telephone Number	:	561-843-9060

Provider Enumeration Date	:	06/26/2018
Last Update Date	:	06/26/2018

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