Provider Demographics
NPI:1023846730
Name:HOMAYOON, MAKENNA (RBT)
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:
Last Name:HOMAYOON
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 1:12617 OAK HILL WAY
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-5518
Mailing Address - Country:US
Mailing Address - Phone:727-922-3163
Mailing Address - Fax:
Practice Address - Street 1:3311 77TH CT E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-2588
Practice Address - Country:US
Practice Address - Phone:941-218-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-354334106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician