Provider Demographics
NPI:1134623366
Name:BEHAVIORAL THERAPEUTIC ALT
Entity type:Organization
Organization Name:BEHAVIORAL THERAPEUTIC ALT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERLANDO
Authorized Official - Middle Name:O
Authorized Official - Last Name:CIVILE
Authorized Official - Suffix:
Authorized Official - Credentials:CASE MANAGER
Authorized Official - Phone:786-355-0984
Mailing Address - Street 1:6473 SW 158TH PASS
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-3672
Mailing Address - Country:US
Mailing Address - Phone:786-444-0578
Mailing Address - Fax:
Practice Address - Street 1:12905 SW 42ND ST STE 207
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-2912
Practice Address - Country:US
Practice Address - Phone:786-444-0578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty