Provider Demographics
NPI:1003673625
Name:MOSTAFFA DI MARTINO, LUCIA GABRIELA (RBT)
Entity type:Individual
Prefix:
First Name:LUCIA
Middle Name:GABRIELA
Last Name:MOSTAFFA DI MARTINO
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 1:1509 E COLONIAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4729
Mailing Address - Country:US
Mailing Address - Phone:407-317-5429
Mailing Address - Fax:321-800-7201
Practice Address - Street 1:2134 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4535
Practice Address - Country:US
Practice Address - Phone:407-317-5429
Practice Address - Fax:321-800-7201
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122055700Medicaid