Basic Information
| Provider Information | |||||||||
| NPI: | 1306202940 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BREAKTHROUGH BEHAVIOR, LLC | ||||||||
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| OtherOrganizationName: | BREAKTHROUGH BEHAVIOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 MAITLAND CENTER PKWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075744629 | ||||||||
| FaxNumber: | 4079654480 | ||||||||
| Practice Location | |||||||||
| Address1: | 12702 SCIENCE DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328263016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075744629 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2016 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | MAEGEN | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4075744631 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 106E00000X | N | 193200000X MULTI-SPECIALTY GROUP | 2355S0801X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 107474800 | 05 | FL | MEDICAID |