Healthcare Provider Details

I. General information

NPI: 1669226056
Provider Name (Legal Business Name): JOHANNY LICELOT GUZMAN ROMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5865 CARIBBEAN BLVD APT 4305
WEST PALM BEACH FL
33407-1797
US

IV. Provider business mailing address

5865 CARIBBEAN BLVD APT 4305
WEST PALM BEACH FL
33407-1797
US

V. Phone/Fax

Practice location:
  • Phone: 561-507-4636
  • Fax:
Mailing address:
  • Phone: 561-507-4636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-339888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: