Healthcare Provider Details

I. General information

NPI: 1023608544
Provider Name (Legal Business Name): ENMANUEL TESOURO RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ENMANUEL TESOURO RBT

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 W ATLANTIC AVE STE 112
DELRAY BEACH FL
33484-8103
US

IV. Provider business mailing address

201 BONNIE BLVD APT 117
PALM SPRINGS FL
33461-1319
US

V. Phone/Fax

Practice location:
  • Phone: 561-674-9996
  • Fax:
Mailing address:
  • Phone: 561-566-2681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number20149895
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: