Provider Demographics
NPI:1609312107
Name:BAVARESCO, IRINA
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:BAVARESCO
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 1:10300 SUNSET DR STE 114
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-3038
Mailing Address - Country:US
Mailing Address - Phone:305-508-5580
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:10300 SUNSET DR STE 114
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3038
Practice Address - Country:US
Practice Address - Phone:305-508-5580
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-55389106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician