Provider Demographics
NPI:1356904536
Name:GARCIA BERMUDEZ, JOHNNALITZ
Entity type:Individual
Prefix:
First Name:JOHNNALITZ
Middle Name:
Last Name:GARCIA BERMUDEZ
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 1:2000 N CONGRESS AVE LOT 188
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-6346
Mailing Address - Country:US
Mailing Address - Phone:561-475-8296
Mailing Address - Fax:
Practice Address - Street 1:6415 LAKE WORTH RD STE 204
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-2904
Practice Address - Country:US
Practice Address - Phone:561-771-9561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-82572106S00000X
FL0-24-15576106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103757800Medicaid