Provider Demographics
NPI:1043078710
Name:VIVANCO, JUDITH (RBT-24-3227486)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:VIVANCO
Suffix:
Gender:F
Credentials:RBT-24-3227486
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 NW 4TH AVE
Mailing Address - Street 2:APT 501
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1565
Mailing Address - Country:US
Mailing Address - Phone:786-597-2703
Mailing Address - Fax:
Practice Address - Street 1:1699 NW 4TH AVE
Practice Address - Street 2:APT 501
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1565
Practice Address - Country:US
Practice Address - Phone:786-597-2703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-327486106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician