Healthcare Provider Details

I. General information

NPI: 1376222752
Provider Name (Legal Business Name): IVONNE M ASENCIO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MIRANDA LN
KISSIMMEE FL
34741-0769
US

IV. Provider business mailing address

2752 PATRICIAN CIR
KISSIMMEE FL
34746-3293
US

V. Phone/Fax

Practice location:
  • Phone: 407-494-3787
  • Fax: 888-584-9071
Mailing address:
  • Phone: 787-317-2673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY11826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: