Provider Demographics
NPI:1588552657
Name:LUCKY CLOVER ABA LLC
Entity type:Organization
Organization Name:LUCKY CLOVER ABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-598-9851
Mailing Address - Street 1:1810 E KNOLLWOOD ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-3465
Mailing Address - Country:US
Mailing Address - Phone:813-598-9851
Mailing Address - Fax:
Practice Address - Street 1:1810 E KNOLLWOOD ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-3465
Practice Address - Country:US
Practice Address - Phone:813-598-9851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services