Healthcare Provider Details

I. General information

NPI: 1609146406
Provider Name (Legal Business Name): JUANITA CARBAJAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 LAKE ELLENOR DR STE 212
ORLANDO FL
32809-4632
US

IV. Provider business mailing address

6100 LAKE ELLENOR DR STE 212
ORLANDO FL
32809-4632
US

V. Phone/Fax

Practice location:
  • Phone: 407-325-2235
  • Fax:
Mailing address:
  • Phone: 407-325-2235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: