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General NPI Number Information
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NPI Number | 1265043392
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Entity Type | Individual
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Provider Name | NICOLE IBANEZ
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Gender | Female
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Dates
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Enumeration Date | 08/12/2020
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Last Update Date | 09/13/2022
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Provider Practice Location Address
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Address Line | 1590 TROPIC PARK DR
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City | SANFORD
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State | FL
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Zip | 32773-6323
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Country | US
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Telephone | 407-202-2220
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Fax | 407-369-4307
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Provider Business Mailing Address
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Address Line | 121 N HIGHLAND ST
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City | MOUNT DORA
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State | FL
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Zip | 32757-5764
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Country | US
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Telephone | 352-720-5194
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Fax | 407-386-7133
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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