Healthcare Provider Details

I. General information

NPI: 1568913036
Provider Name (Legal Business Name): LUANN BERTAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 W HIBISCUS BLVD
MELBOURNE FL
32901-2622
US

IV. Provider business mailing address

1855 W HIBISCUS BLVD
MELBOURNE FL
32901-2622
US

V. Phone/Fax

Practice location:
  • Phone: 321-345-4232
  • Fax: 321-765-6434
Mailing address:
  • Phone: 321-345-4232
  • Fax: 321-765-6434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-05-2134
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: