Provider Demographics
NPI:1285180117
Name:RODRIGUEZ-MANCILLA, AMBAR DIANETH
Entity Type:Individual
Prefix:
First Name:AMBAR
Middle Name:DIANETH
Last Name:RODRIGUEZ-MANCILLA
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 1:2200 RIO PINAR LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8422
Mailing Address - Country:US
Mailing Address - Phone:407-274-1120
Mailing Address - Fax:
Practice Address - Street 1:222 BROADWAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5781
Practice Address - Country:US
Practice Address - Phone:407-329-3464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 103K00000X
FL1-24-70809103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108221600Medicaid