Provider Demographics
NPI:1275061616
Name:PRUNA, GENESIS NICHELLE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:GENESIS
Middle Name:NICHELLE
Last Name:PRUNA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:GENESIS
Other - Middle Name:NICHELLE
Other - Last Name:AQUINO MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:419 W 49TH ST STE 210
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3657
Practice Address - Country:US
Practice Address - Phone:305-822-9063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL247200000X
FL1193954103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other