Provider Demographics
NPI:1760245823
Name:CANTELOPE PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:CANTELOPE PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDJELA
Authorized Official - Middle Name:
Authorized Official - Last Name:AVRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-368-1087
Mailing Address - Street 1:7202 DELLA DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5139
Mailing Address - Country:US
Mailing Address - Phone:321-368-1087
Mailing Address - Fax:
Practice Address - Street 1:7202 DELLA DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5139
Practice Address - Country:US
Practice Address - Phone:321-368-1087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty