MEDICARE: MABANZA RENEE KANAMA

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	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215423207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MABANZA RENEE KANAMA

Provider Business Mailing Address
First Line	:	14402 AVALON RESERVE BLVD APT 201
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-5143
Country	:	US
Telephone Number	:	407-683-7932
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 S RONALD REAGAN BLVD STE 106
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-5466
Country	:	US
Telephone Number	:	321-328-7003
Fax Number	:

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

Provider Enumeration Date	:	07/03/2018
Last Update Date	:	07/03/2018

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Directions to “ MABANZA RENEE KANAMA ” Practice Location

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