Healthcare Provider Details

I. General information

NPI: 1245820117
Provider Name (Legal Business Name): HEROL GUSTAVO PEREZ ENCARNACION RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 EXCHANGE CT
WEST PALM BEACH FL
33409-4017
US

IV. Provider business mailing address

13934 MORNING GLORY DR
WELLINGTON FL
33414-8611
US

V. Phone/Fax

Practice location:
  • Phone: 561-900-5504
  • Fax:
Mailing address:
  • Phone: 561-215-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-152152
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: