MEDICARE: LIUBYS MATEU IZQUIERDO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-24-353957	FL

General Provider Information

NPI Number	:	1093558926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIUBYS MATEU IZQUIERDO

Provider Business Mailing Address
First Line	:	855 NE 6TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-2062
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 NE 6TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-2062
Country	:	US
Telephone Number	:	239-240-1651
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2024
Last Update Date	:	06/18/2024

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