Provider Demographics
NPI:1235740572
Name:MA MC SPROUT 1 LLC
Entity Type:Organization
Organization Name:MA MC SPROUT 1 LLC
Other - Org Name:SPROUT THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGHEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-210-8200
Mailing Address - Street 1:6303 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-6040
Mailing Address - Country:US
Mailing Address - Phone:833-991-2368
Mailing Address - Fax:929-384-7193
Practice Address - Street 1:90 CANAL ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2018
Practice Address - Country:US
Practice Address - Phone:833-991-2368
Practice Address - Fax:929-384-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty