Basic Information
Provider Information | |||||||||
NPI: | 1568130136 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BREAKTHROUGH BEHAVIOR LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BREAKTHROUGH BEHAVIOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2301 MAITLAND CENTER PKWY STE 240 | ||||||||
Address2: |   | ||||||||
City: | MAITLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 327517415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10817 BLOOMINGDALE AVE | ||||||||
Address2: |   | ||||||||
City: | RIVERVIEW | ||||||||
State: | FL | ||||||||
PostalCode: | 335783616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8133241342 | ||||||||
FaxNumber: | 4079654480 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2021 | ||||||||
LastUpdateDate: | 05/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PIERCE | ||||||||
AuthorizedOfficialFirstName: | MAEGEN | ||||||||
AuthorizedOfficialMiddleName: | CHRISTINE | ||||||||
AuthorizedOfficialTitleorPosition: | FOUNDER CEO | ||||||||
AuthorizedOfficialTelephone: | 4075744629 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BREAKTHROUGH BEHAVIOR, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MA, BCBA, LBA | ||||||||
NPICertificationDate: | 05/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 103K00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 107474804 | 05 | FL |   | MEDICAID |