Basic Information
Provider Information | |||||||||
NPI: | 1871099689 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMERICAN THERAPY HOUSE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1495 N PARK DR | ||||||||
Address2: |   | ||||||||
City: | WESTON | ||||||||
State: | FL | ||||||||
PostalCode: | 333263215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9546089930 | ||||||||
FaxNumber: | 9542416726 | ||||||||
Practice Location | |||||||||
Address1: | 4959 PALO VERDE ST STE 105C | ||||||||
Address2: |   | ||||||||
City: | MONTCLAIR | ||||||||
State: | CA | ||||||||
PostalCode: | 917632359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099290743 | ||||||||
FaxNumber: | 9542416726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2018 | ||||||||
LastUpdateDate: | 04/02/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DE OLIVEIRA | ||||||||
AuthorizedOfficialFirstName: | EILEEN | ||||||||
AuthorizedOfficialMiddleName: | SUE | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9546089930 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.