Provider Demographics
NPI:1356061154
Name:LLANES, IDALYS D
Entity type:Individual
Prefix:
First Name:IDALYS
Middle Name:D
Last Name:LLANES
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 1:808 NEPTUNE POINTE LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5932
Mailing Address - Country:US
Mailing Address - Phone:786-301-4974
Mailing Address - Fax:
Practice Address - Street 1:808 NEPTUNE POINTE LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5932
Practice Address - Country:US
Practice Address - Phone:786-301-4974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-141213106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician