Provider Demographics
NPI:1942081781
Name:LIFE TEAM FOR CHILDREN WITH AUTISM
Entity Type:Organization
Organization Name:LIFE TEAM FOR CHILDREN WITH AUTISM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-290-1602
Mailing Address - Street 1:675 PERDIDO HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33413-1099
Mailing Address - Country:US
Mailing Address - Phone:386-290-1602
Mailing Address - Fax:
Practice Address - Street 1:675 PERDIDO HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33413-1099
Practice Address - Country:US
Practice Address - Phone:386-290-1602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty