Healthcare Provider Details

I. General information

NPI: 1538813480
Provider Name (Legal Business Name): JUSTIN TERRENCE BAROLETTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12702 SCIENCE DR
ORLANDO FL
32826-3016
US

IV. Provider business mailing address

5620 THYER ST
NORTH PORT FL
34288-4308
US

V. Phone/Fax

Practice location:
  • Phone: 407-574-2073
  • Fax:
Mailing address:
  • Phone: 941-380-1782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-201571
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: