Provider Demographics
NPI:1821520503
Name:MBKNOWLES
Entity Type:Organization
Organization Name:MBKNOWLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:BRITTANY
Authorized Official - Last Name:KNOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-284-1873
Mailing Address - Street 1:2065 SE LENNARD RD APT 307
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-284-1873
Mailing Address - Fax:772-207-5808
Practice Address - Street 1:2065 SE LENNARD RD APT 307
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4753
Practice Address - Country:US
Practice Address - Phone:772-284-1873
Practice Address - Fax:772-207-5808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017716200Medicaid