Healthcare Provider Details

I. General information

NPI: 1205429511
Provider Name (Legal Business Name): EVANISE PERICLES RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 FERGUSON DR STE 200
ORLANDO FL
32805-1023
US

IV. Provider business mailing address

6739 MERITMOOR CIR
ORLANDO FL
32818-2288
US

V. Phone/Fax

Practice location:
  • Phone: 407-574-4629
  • Fax:
Mailing address:
  • Phone: 407-272-6533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: