MEDICARE: EMMA ANESA ANTANAVICIUS

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

General Provider Information

NPI Number	:	1538995204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA ANESA ANTANAVICIUS

Provider Business Mailing Address
First Line	:	1500 S DOUGLAS RD STE 230
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-4108
Country	:	US
Telephone Number	:	844-244-1818
Fax Number	:

Provider Business Practice Location Address
First Line	:	8390 CHAMPIONS GATE BLVD
Second Line	:
City	:	CHAMPIONS GATE
State	:	FL
Zip	:	33896-8310
Country	:	US
Telephone Number	:	854-844-1116
Fax Number	:

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

Provider Enumeration Date	:	09/10/2024
Last Update Date	:	09/10/2024

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