MEDICARE: TIME TO SHINE LICENSED BEHAVIOR ANALYSIS PLLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1316717275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIME TO SHINE LICENSED BEHAVIOR ANALYSIS PLLC

Provider Business Mailing Address
First Line	:	557 GRAND CONCOURSE STE 3-221
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10451-5253
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	557 GRAND CONCOURSE STE 3-221
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10451-5253
Country	:	US
Telephone Number	:	347-585-0713
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PEARL GOLDWURM
Credential	:
Telephone Number	:	347-585-0713

Provider Enumeration Date	:	01/03/2024
Last Update Date	:	01/03/2024

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