MEDICARE: IRASEL MESA R.B.T

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	102912500	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447914783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRASEL MESA R.B.T

Provider Business Mailing Address
First Line	:	4051 SW 154TH CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33185-5416
Country	:	US
Telephone Number	:	786-603-9158
Fax Number	:

Provider Business Practice Location Address
First Line	:	4051 SW 154TH CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33185-5416
Country	:	US
Telephone Number	:	786-603-9158
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2021
Last Update Date	:	10/22/2021

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