Provider Demographics
NPI:1922721752
Name:VEGA PUCH, GISELLE (RBT)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:VEGA PUCH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 SE 23RD PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1959
Mailing Address - Country:US
Mailing Address - Phone:786-715-1971
Mailing Address - Fax:
Practice Address - Street 1:1500 COLONIAL BLVD STE 208
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1025
Practice Address - Country:US
Practice Address - Phone:239-260-4218
Practice Address - Fax:239-900-1283
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-221546106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty