MEDICARE: INNOVATIVE MINDS ABA

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		FL
2	106S00000X	Behavior Technician
3	101YS0200X	School Counselor
4	252Y00000X	Early Intervention Provider Agency
5	225X00000X	Occupational Therapist	OT15768	FL

General Provider Information

NPI Number	:	1811487705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE MINDS ABA

Provider Business Mailing Address
First Line	:	8848 SW 211TH LN
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33189-3124
Country	:	US
Telephone Number	:	305-321-7817
Fax Number	:

Provider Business Practice Location Address
First Line	:	8848 SW 211TH LN
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33189
Country	:	US
Telephone Number	:	305-321-7817
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SUZETTE FRAGINALS
Credential	:	ED.S
Telephone Number	:	305-321-7817

Provider Enumeration Date	:	05/16/2018
Last Update Date	:	05/17/2018

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