Healthcare Provider Details

I. General information

NPI: 1134734288
Provider Name (Legal Business Name): IDALIA JUNCO RBT-20-133734
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20001 NW 52ND CT
MIAMI GARDENS FL
33055-4692
US

IV. Provider business mailing address

20001 NW 52ND CT
MIAMI GARDENS FL
33055-4692
US

V. Phone/Fax

Practice location:
  • Phone: 786-452-2422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-133734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: