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General NPI Number Information
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NPI Number | 1205526076
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Entity Type | Individual
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Provider Name | MRS. MALLORY HOLGUIN
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Gender | Female
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Dates
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Enumeration Date | 05/15/2023
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Last Update Date | 05/15/2023
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Provider Practice Location Address
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Address Line | 1801 SE HILLMOOR DR STE B-101
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34952-7545
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Country | US
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Telephone | 772-219-7575
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Fax |
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Provider Business Mailing Address
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Address Line | 1270 SW ARAGON AVE
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-4823
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Country | US
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Telephone | 772-877-9755
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-23-273389
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License Number State | FL
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