MEDICARE: ROSA NELIDA JORDAN BASTART

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-22-210061	FL

General Provider Information

NPI Number	:	1255285318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSA NELIDA JORDAN BASTART

Provider Business Mailing Address
First Line	:	824 SE 5TH AVE
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-2819
Country	:	US
Telephone Number	:	239-763-2663
Fax Number	:

Provider Business Practice Location Address
First Line	:	824 SE 5TH AVE
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-2819
Country	:	US
Telephone Number	:	239-763-2663
Fax Number	:

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

Provider Enumeration Date	:	02/25/2026
Last Update Date	:	02/25/2026

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Directions to “ ROSA NELIDA JORDAN BASTART ” Practice Location

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