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1790 Sw 43rd Way Fort Lauderdale FL 33317-5701 | |
| (954) 584-8000 | |
| (954) 206-7699 |
| Full Name | |
|---|---|
| Speciality | Behavior Analyst |
| Location | 1790 Sw 43rd Way, Fort Lauderdale, Florida |
| Authorized Official Name and Position | Tonita Gregory (DIRECTOR OF ACCOUNTING) |
| Authorized Official Contact | 9545848000 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1790 Sw 43rd Way Fort Lauderdale FL 33317-5701 Ph: (954) 584-8000 | 1790 Sw 43rd Way Fort Lauderdale FL 33317-5701 Ph: (954) 584-8000 |
| NPI Number | 1750898631 |
|---|---|
| Provider Enumeration Date | 01/02/2018 |
| Last Update Date | 02/11/2021 |
| Certification Date | 02/11/2021 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1750898631 | NPI | - | NPPES |
| 019879600 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103K00000X | Behavior Analyst | 1-10-6883 (* (Not Available)) | Primary |
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