MEDICARE: LIFESPROUT, 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	1-07-3256	FL

General Provider Information

NPI Number	:	1952549982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESPROUT, LLC

Provider Business Mailing Address
First Line	:	1115 GOLDEN LAKES BLVD APT 524
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-3331
Country	:	US
Telephone Number	:	561-596-8791
Fax Number	:	561-471-1332

Provider Business Practice Location Address
First Line	:	1115 GOLDEN LAKES BLVD APT 524
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-3331
Country	:	US
Telephone Number	:	561-596-8791
Fax Number	:	561-471-1332

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	ROCCO L. NOCERA
Credential	:	MA, BCBA
Telephone Number	:	561-596-8791

Provider Enumeration Date	:	01/29/2009
Last Update Date	:	01/29/2009

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