Provider Demographics
NPI:1053069435
Name:FABREGAS MANTILLA, GUYEN
Entity Type:Individual
Prefix:
First Name:GUYEN
Middle Name:
Last Name:FABREGAS MANTILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25097 SW 124TH CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5948
Mailing Address - Country:US
Mailing Address - Phone:305-746-0171
Mailing Address - Fax:
Practice Address - Street 1:25097 SW 124TH CT
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5948
Practice Address - Country:US
Practice Address - Phone:305-746-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-59808106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician