Provider Demographics
NPI:1588480974
Name:MICHELENA, GLORIMAR
Entity Type:Individual
Prefix:
First Name:GLORIMAR
Middle Name:
Last Name:MICHELENA
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 1:3102 ANITA AVE S
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976-4036
Mailing Address - Country:US
Mailing Address - Phone:239-391-4492
Mailing Address - Fax:
Practice Address - Street 1:3900 COLONIAL BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1014
Practice Address - Country:US
Practice Address - Phone:239-351-3715
Practice Address - Fax:239-310-2045
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-389588106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician