Provider Demographics
NPI:1194437202
Name:ENERGY BEHAVIORAL THERAPY CORP
Entity type:Organization
Organization Name:ENERGY BEHAVIORAL THERAPY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ TANQUERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-227-2966
Mailing Address - Street 1:1701 SE TIFFANY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7576
Mailing Address - Country:US
Mailing Address - Phone:786-227-2966
Mailing Address - Fax:
Practice Address - Street 1:1701 SE TIFFANY AVE STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7576
Practice Address - Country:US
Practice Address - Phone:786-227-2966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty