Healthcare Provider Details

I. General information

NPI: 1992578512
Provider Name (Legal Business Name): VISMERY GONZALEZ BORRAJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11745 SW 169TH TER
MIAMI FL
33177-2153
US

IV. Provider business mailing address

11745 SW 169TH TER
MIAMI FL
33177-2153
US

V. Phone/Fax

Practice location:
  • Phone: 786-343-3036
  • Fax:
Mailing address:
  • Phone: 786-343-3036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-272036
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: