Healthcare Provider Details

I. General information

NPI: 1255101317
Provider Name (Legal Business Name): GWENDOLYN VIOLET LEE MAXWELL RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 SE 100TH PL
BELLEVIEW FL
34420-3013
US

IV. Provider business mailing address

4611 SE 100TH PL
BELLEVIEW FL
34420-3013
US

V. Phone/Fax

Practice location:
  • Phone: 352-559-2539
  • Fax: 352-547-5787
Mailing address:
  • Phone: 352-559-2539
  • Fax: 352-547-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-291977
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: