Healthcare Provider Details

I. General information

NPI: 1184282980
Provider Name (Legal Business Name): ELLYN JOANN CUEVAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3771 STEFANI RD
CANTONMENT FL
32533-7795
US

IV. Provider business mailing address

3771 STEFANI RD
CANTONMENT FL
32533-7795
US

V. Phone/Fax

Practice location:
  • Phone: 850-607-6910
  • Fax: 850-607-6932
Mailing address:
  • Phone: 850-607-6910
  • Fax: 850-607-6932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-88866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: