Basic Information
| Provider Information | |||||||||
| NPI: | 1811665482 | ||||||||
| EntityType: | 2 | ||||||||
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| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 644 FERGUSON DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328051023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075744629 | ||||||||
| FaxNumber: | 4079654480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2021 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | MAEGEN | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | FOUNDER CEO | ||||||||
| AuthorizedOfficialTelephone: | 4075744629 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BREAKTHROUGH BEHAVIOR, LLC | ||||||||
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| 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 | 107474801 | 05 | FL | MEDICAID |