Provider Demographics
NPI:1710157052
Name:THE SHAPING ACADEMY FOR BEHAVIORAL DEVELOPMENT
Entity Type:Organization
Organization Name:THE SHAPING ACADEMY FOR BEHAVIORAL DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:YANIVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LMHC
Authorized Official - Phone:305-562-4683
Mailing Address - Street 1:12930 SW 128TH ST
Mailing Address - Street 2:SUITE 204A1
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6038
Mailing Address - Country:US
Mailing Address - Phone:305-562-4683
Mailing Address - Fax:866-517-3411
Practice Address - Street 1:12930 SW 128TH ST
Practice Address - Street 2:SUITE 204A1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6038
Practice Address - Country:US
Practice Address - Phone:305-562-4683
Practice Address - Fax:866-517-3411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 11547251S00000X
FL1-12-10380251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health