Provider Demographics
NPI:1245801018
Name:GUERRA RODRIGUEZ, IVELYN (RBT)
Entity Type:Individual
Prefix:
First Name:IVELYN
Middle Name:
Last Name:GUERRA RODRIGUEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 19TH AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-6064
Mailing Address - Country:US
Mailing Address - Phone:561-377-9760
Mailing Address - Fax:
Practice Address - Street 1:1508 19TH AVE N # 561
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-6064
Practice Address - Country:US
Practice Address - Phone:561-377-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-02
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
FLRBT21-159043106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110625000Medicaid