Provider Demographics
NPI:1326891029
Name:FORMENTIN ZAYAS, YANIXET MILAGRO I (RBT)
Entity Type:Individual
Prefix:MS
First Name:YANIXET
Middle Name:MILAGRO
Last Name:FORMENTIN ZAYAS
Suffix:I
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 1:180 ROYAL PALM DR APT 104
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-4075
Mailing Address - Country:US
Mailing Address - Phone:321-566-5314
Mailing Address - Fax:
Practice Address - Street 1:180 ROYAL PALM DR
Practice Address - Street 2:APTO 104
Practice Address - City:KISSIMME
Practice Address - State:FL
Practice Address - Zip Code:34743-4075
Practice Address - Country:US
Practice Address - Phone:321-566-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24333603106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician