Healthcare Provider Details

I. General information

NPI: 1316636095
Provider Name (Legal Business Name): JANISHKA KELANIE BAEZ BEHAVIOR TECHNICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 36TH ST SE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

1500 S DOUGLAS RD STE 230
CORAL GABLES FL
33134-4108
US

V. Phone/Fax

Practice location:
  • Phone: 616-512-2781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: