Healthcare Provider Details

I. General information

NPI: 1003607714
Provider Name (Legal Business Name): VANESSA DORE BACB1156968
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8415 SW 24TH ST
MIAMI FL
33155-2305
US

IV. Provider business mailing address

6430 SW 30TH ST
MIAMI FL
33155-3912
US

V. Phone/Fax

Practice location:
  • Phone: 305-262-6868
  • Fax:
Mailing address:
  • Phone: 786-527-4597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBACB1156968
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: