Provider Demographics
NPI:1760182026
Name:INFANTE GOUBERNEUR, ETELVINA
Entity Type:Individual
Prefix:
First Name:ETELVINA
Middle Name:
Last Name:INFANTE GOUBERNEUR
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 1:9755 NW 52ND ST APT 405
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2075
Mailing Address - Country:US
Mailing Address - Phone:786-823-1118
Mailing Address - Fax:
Practice Address - Street 1:9755 NW 52ND ST APT 405
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2075
Practice Address - Country:US
Practice Address - Phone:786-823-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist