Provider Demographics
NPI:1811628951
Name:LIGHT OF HOPE BEHAVIOR THERAPY INC
Entity Type:Organization
Organization Name:LIGHT OF HOPE BEHAVIOR THERAPY INC
Other - Org Name:LIGHT OF HOPE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:H
Authorized Official - Last Name:PEREZ GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-404-1008
Mailing Address - Street 1:15190 SW 136TH ST STE 26
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-2618
Mailing Address - Country:US
Mailing Address - Phone:786-404-1008
Mailing Address - Fax:305-747-7166
Practice Address - Street 1:15190 SW 136TH ST STE 26-27
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-2604
Practice Address - Country:US
Practice Address - Phone:786-404-1008
Practice Address - Fax:305-747-7166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-20
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115780900Medicaid