Healthcare Provider Details

I. General information

NPI: 1205209038
Provider Name (Legal Business Name): VIVIAN IBANEZ M.A., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 NW 56TH TER
GAINESVILLE FL
32605-4481
US

IV. Provider business mailing address

PO BOX 100256
GAINESVILLE FL
32610-0256
US

V. Phone/Fax

Practice location:
  • Phone: 352-835-5520
  • Fax:
Mailing address:
  • Phone: 352-265-4357
  • Fax: 352-392-3614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-15-19872
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: