Healthcare Provider Details

I. General information

NPI: 1376364109
Provider Name (Legal Business Name): MARIO FERNANDEZ RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 CORPORATE WAY STE 101
WEST PALM BEACH FL
33407-2039
US

IV. Provider business mailing address

221 WENONAH PL APT 3
WEST PALM BEACH FL
33405-1965
US

V. Phone/Fax

Practice location:
  • Phone: 561-328-8643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-376496
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: