Healthcare Provider Details

I. General information

NPI: 1760942528
Provider Name (Legal Business Name): LEYRA INES CUETO ULACIO RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 S US HIGHWAY 1 STE 2
PORT ST LUCIE FL
34952-6407
US

IV. Provider business mailing address

10850 S US HIGHWAY 1 STE 2
PORT ST LUCIE FL
34952-6407
US

V. Phone/Fax

Practice location:
  • Phone: 772-446-3044
  • Fax:
Mailing address:
  • Phone: 321-750-9925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-80634
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: