Provider Demographics
NPI:1700375771
Name:IACCARINO, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:IACCARINO
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 1:153 SEVILLA AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1117
Mailing Address - Country:US
Mailing Address - Phone:561-758-0907
Mailing Address - Fax:
Practice Address - Street 1:9815 CROSS PINE CT
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2367
Practice Address - Country:US
Practice Address - Phone:561-223-8076
Practice Address - Fax:561-584-5372
Is Sole Proprietor?:No
Enumeration Date:2018-05-05
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
FLRBT-21-160634106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10650000XMedicaid
FL10650000XMedicaid