Provider Demographics
NPI:1609539675
Name:BLUEMIND ABA THERAGROUP LLC
Entity Type:Organization
Organization Name:BLUEMIND ABA THERAGROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-764-1554
Mailing Address - Street 1:1700 N DIXIE HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-1807
Mailing Address - Country:US
Mailing Address - Phone:305-764-1554
Mailing Address - Fax:
Practice Address - Street 1:1700 N DIXIE HWY STE 100
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-1807
Practice Address - Country:US
Practice Address - Phone:305-764-1554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty