Provider Demographics
NPI:1629477195
Name:JUSTINIANO, VIVIAN
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:
Last Name:JUSTINIANO
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 1:10627 CROCUS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6707
Mailing Address - Country:US
Mailing Address - Phone:407-801-5138
Mailing Address - Fax:
Practice Address - Street 1:1975 S JOHN YOUNG PKWY
Practice Address - Street 2:SUITE 203A
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0603
Practice Address - Country:US
Practice Address - Phone:321-236-1540
Practice Address - Fax:321-594-6096
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30458374Medicaid