Provider Demographics
NPI:1578282059
Name:SUPPORT THERAPY GROUP LLC
Entity type:Organization
Organization Name:SUPPORT THERAPY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIELYS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ IZQUIERDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-966-2583
Mailing Address - Street 1:3420 AIRFIELD DRIVE E
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811
Mailing Address - Country:US
Mailing Address - Phone:646-966-2583
Mailing Address - Fax:
Practice Address - Street 1:3420 AIRFIELD DRIVE E
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811
Practice Address - Country:US
Practice Address - Phone:646-966-2583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-26
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech