Healthcare Provider Details

I. General information

NPI: 1700586385
Provider Name (Legal Business Name): NICOLE RONQUILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BRICKELL AVE STE 500
MIAMI FL
33131-2803
US

IV. Provider business mailing address

8467 SW 166TH PL
MIAMI FL
33193-5790
US

V. Phone/Fax

Practice location:
  • Phone: 305-330-4660
  • Fax:
Mailing address:
  • Phone: 908-485-0772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberR524-620-02-864-0
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberR524-620-02-864-0
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberR524-620-02-864-0
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: