MEDICARE: IMAGINARY WORLD, 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	:	1912594078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGINARY WORLD, LLC

Provider Business Mailing Address
First Line	:	2977 GOODLETTE-FRANK RD N STE 14
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34103-4613
Country	:	US
Telephone Number	:	786-468-1087
Fax Number	:

Provider Business Practice Location Address
First Line	:	2977 GOODLETTE-FRANK RD N STE 14
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34103-4613
Country	:	US
Telephone Number	:	786-468-1087
Fax Number	:

Authorized Official
Title or Position	:	BCBA
Name	:	MARTHA HERNANDEZ
Credential	:	BCBA
Telephone Number	:	786-468-1087

Provider Enumeration Date	:	12/23/2020
Last Update Date	:	03/27/2024

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