Healthcare Provider Details

I. General information

NPI: 1114810785
Provider Name (Legal Business Name): JASMINE ALYSSA REVAN RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 ANTILLA AVE
CORAL GABLES FL
33134-3301
US

IV. Provider business mailing address

9949 NW 27TH TER
DORAL FL
33172-1314
US

V. Phone/Fax

Practice location:
  • Phone: 305-567-5881
  • Fax:
Mailing address:
  • Phone: 305-926-1368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-26-2835147
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: