MEDICARE: LIGHT ANGELS BEHAVIORAL THERAPY INC

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	Behavioral 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	:	1306452578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHT ANGELS BEHAVIORAL THERAPY INC

Provider Business Mailing Address
First Line	:	2240 PALM BEACH LAKES BLVD STE 400-E
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-3410
Country	:	US
Telephone Number	:	786-709-7932
Fax Number	:

Provider Business Practice Location Address
First Line	:	2240 PALM BEACH LAKES BLVD STE 400-E
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-3410
Country	:	US
Telephone Number	:	786-709-7932
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	ANDY VEGA
Credential	:
Telephone Number	:	786-709-7932

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	09/22/2020

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