Provider Demographics
NPI:1255946729
Name:LLANES BASULTO, YASMANI
Entity type:Individual
Prefix:
First Name:YASMANI
Middle Name:
Last Name:LLANES BASULTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 SW 106TH TER APT 536
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-2749
Mailing Address - Country:US
Mailing Address - Phone:786-210-8380
Mailing Address - Fax:
Practice Address - Street 1:15924 SW 92ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-1842
Practice Address - Country:US
Practice Address - Phone:305-964-5824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20752101YM0800X
FL1-20-43537103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health