Healthcare Provider Details

I. General information

NPI: 1134635782
Provider Name (Legal Business Name): VIERGELA CAMILUS QBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 SPANISH RIVER RD
FORT PIERCE FL
34951-2898
US

IV. Provider business mailing address

5525 SPANISH RIVER RD
FORT PIERCE FL
34951-2898
US

V. Phone/Fax

Practice location:
  • Phone: 561-856-0257
  • Fax:
Mailing address:
  • Phone: 561-856-0257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: