MEDICARE: MICAYLA CHARITE RBT

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	247200000X	Other Technician	RBT-15-09265	FL

General Provider Information

NPI Number	:	1649638032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICAYLA CHARITE RBT

Provider Business Mailing Address
First Line	:	1602 SE WALTON LAKES DR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5107
Country	:	US
Telephone Number	:	772-985-5353
Fax Number	:

Provider Business Practice Location Address
First Line	:	1602 SE WALTON LAKES DR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5107
Country	:	US
Telephone Number	:	772-985-5353
Fax Number	:

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

Provider Enumeration Date	:	02/01/2016
Last Update Date	:	02/01/2016

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Directions to “ MICAYLA CHARITE RBT” Practice Location

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