Healthcare Provider Details

I. General information

NPI: 1568299915
Provider Name (Legal Business Name): JEANETH HUANCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 NW 79TH AVE APT 1A
DORAL FL
33166-6344
US

IV. Provider business mailing address

4370 NW 79TH AVE APT 1A
DORAL FL
33166-6344
US

V. Phone/Fax

Practice location:
  • Phone: 305-607-7085
  • Fax:
Mailing address:
  • Phone: 305-607-7085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT24324599
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: