Provider Demographics
NPI:1790480903
Name:BACALLAO LLANIO, IVETTE MARIA
Entity Type:Individual
Prefix:
First Name:IVETTE
Middle Name:MARIA
Last Name:BACALLAO LLANIO
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 1:5020 S RAINBOW BLVD UNIT 203
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-0661
Mailing Address - Country:US
Mailing Address - Phone:178-639-4095
Mailing Address - Fax:
Practice Address - Street 1:5020 S RAINBOW BLVD UNIT 203
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-0661
Practice Address - Country:US
Practice Address - Phone:178-639-4095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-263248106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician