Healthcare Provider Details

I. General information

NPI: 1255946729
Provider Name (Legal Business Name): YASMANI LLANES BASULTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15924 SW 92ND AVE
MIAMI FL
33157-1842
US

IV. Provider business mailing address

15300 SW 106TH TER APT 536
MIAMI FL
33196-2749
US

V. Phone/Fax

Practice location:
  • Phone: 305-964-5824
  • Fax:
Mailing address:
  • Phone: 786-210-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH20752
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-43537
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: