Provider Demographics
NPI:1407494107
Name:KOURACLES, ELIZABETH BEATRIZ (RBT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BEATRIZ
Last Name:KOURACLES
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 1:440 NW 67TH ST APT 208
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2938
Mailing Address - Country:US
Mailing Address - Phone:561-674-9996
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:561-674-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-105489106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid