Provider Demographics
NPI:1194457903
Name:URDANETA CABELLO, GLAYEN
Entity Type:Individual
Prefix:
First Name:GLAYEN
Middle Name:
Last Name:URDANETA CABELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2868 NOTTEL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-8782
Mailing Address - Country:US
Mailing Address - Phone:404-960-3169
Mailing Address - Fax:
Practice Address - Street 1:1912 RED CANYON DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-6098
Practice Address - Country:US
Practice Address - Phone:689-200-4783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-222554106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty