Healthcare Provider Details

I. General information

NPI: 1114433661
Provider Name (Legal Business Name): MR. JAIME TRAVIESO INCLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 45TH ST STE 202
WEST PALM BEACH FL
33407-2009
US

IV. Provider business mailing address

2151 45TH ST STE 202
WEST PALM BEACH FL
33407-2009
US

V. Phone/Fax

Practice location:
  • Phone: 561-823-8250
  • Fax:
Mailing address:
  • Phone: 561-823-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCBHCMS0102799
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-328358
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: