MEDICARE: SHOOTING STAR BEHAVIORAL SERVICES 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	:	1912695792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOOTING STAR BEHAVIORAL SERVICES LLC

Provider Business Mailing Address
First Line	:	9555 SW 175TH TER # 112
Second Line	:
City	:	PALMETTO BAY
State	:	FL
Zip	:	33157-5604
Country	:	US
Telephone Number	:	786-873-8973
Fax Number	:

Provider Business Practice Location Address
First Line	:	9555 SW 175TH TER # 112
Second Line	:
City	:	PALMETTO BAY
State	:	FL
Zip	:	33157-5604
Country	:	US
Telephone Number	:	786-873-8973
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MALENA RAMOS PEREZ
Credential	:
Telephone Number	:	786-873-8973

Provider Enumeration Date	:	04/28/2023
Last Update Date	:	02/16/2024

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