Provider Demographics
NPI:1225637374
Name:MACIEL BURSTEIN, IGOR LUIZ
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:LUIZ
Last Name:MACIEL BURSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:IGOR
Other - Middle Name:LUIZ
Other - Last Name:MACIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5510 PACIFIC BLVD APT 201
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-6701
Mailing Address - Country:US
Mailing Address - Phone:954-851-4741
Mailing Address - Fax:
Practice Address - Street 1:5180 W ATLANTIC AVE STE 112
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8103
Practice Address - Country:US
Practice Address - Phone:954-851-4741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-20-140815106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician