Provider Demographics
NPI:1821603101
Name:PIVOTAL THERAPY, LLC
Entity Type:Organization
Organization Name:PIVOTAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONDE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA
Authorized Official - Phone:305-707-1600
Mailing Address - Street 1:5810 SW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-5712
Mailing Address - Country:US
Mailing Address - Phone:305-878-6913
Mailing Address - Fax:
Practice Address - Street 1:3081 SALZEDO ST STE 202
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-6725
Practice Address - Country:US
Practice Address - Phone:305-707-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-13
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115187000Medicaid
FL115186700Medicaid
FL024870700Medicaid