MEDICARE: LIVING SOUL OF NEW YORK, 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	:	1528799574
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING SOUL OF NEW YORK, LLC

Provider Business Mailing Address
First Line	:	3175 S CONGRESS AVE STE 204A
Second Line	:
City	:	PALM SPRINGS
State	:	FL
Zip	:	33461-2515
Country	:	US
Telephone Number	:	561-572-6773
Fax Number	:	561-828-9322

Provider Business Practice Location Address
First Line	:	3175 S CONGRESS AVE STE 204A
Second Line	:
City	:	PALM SPRINGS
State	:	FL
Zip	:	33461-2515
Country	:	US
Telephone Number	:	561-536-5888
Fax Number	:	561-828-9322

Authorized Official
Title or Position	:	MGM
Name	:	WIDLINE PIERRE
Credential	:
Telephone Number	:	561-536-5888

Provider Enumeration Date	:	06/21/2022
Last Update Date	:	06/21/2022

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