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General NPI Number Information
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NPI Number | 1982115713
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Entity Type | Individual
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Provider Name | LICET DORTA
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Gender | Female
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Dates
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Enumeration Date | 10/19/2017
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Last Update Date | 08/14/2024
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Provider Practice Location Address
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Address Line | 9234 SW 211TH LN
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City | CUTLER BAY
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State | FL
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Zip | 33189
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Country | US
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Telephone | 786-800-0240
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Fax |
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Provider Business Mailing Address
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Address Line | 9234 SW 211TH LN
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City | CUTLER BAY
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State | FL
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Zip | 33189-3132
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Country | US
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Telephone | 786-663-4948
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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 | 106E00000X
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Taxonomy Name | Assistant Behavior Analyst
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License Number | 0-19-10586
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License Number State | FL
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