Healthcare Provider Details

I. General information

NPI: 1720884950
Provider Name (Legal Business Name): AMANDA JUNCO NOVO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34984-5108
US

IV. Provider business mailing address

2895 SW 144TH PL
MIAMI FL
33175-7444
US

V. Phone/Fax

Practice location:
  • Phone: 772-201-0173
  • Fax: 772-209-7631
Mailing address:
  • Phone: 305-609-1401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-411371
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: