Healthcare Provider Details

I. General information

NPI: 1285412940
Provider Name (Legal Business Name): IDANIA BEJERANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10113 SW 22ND TER
MIAMI FL
33165-7462
US

IV. Provider business mailing address

10113 SW 22ND TER
MIAMI FL
33165-7462
US

V. Phone/Fax

Practice location:
  • Phone: 786-712-6905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-128558
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: