Healthcare Provider Details

I. General information

NPI: 1881281459
Provider Name (Legal Business Name): KEVIN DEJESUS MANZANET
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 12/29/2020
Certification Date: 12/10/2020
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

5180 W ATLANTIC AVE STE 110
DELRAY BEACH FL
33484-8103
US

V. Phone/Fax

Practice location:
  • Phone: 561-674-9996
  • Fax:
Mailing address:
  • Phone: 561-900-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-146706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: