Provider Demographics
NPI:1932879749
Name:TERRY VAILLANT, YUNEISI
Entity Type:Individual
Prefix:
First Name:YUNEISI
Middle Name:
Last Name:TERRY VAILLANT
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 1:1312 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-4512
Mailing Address - Country:US
Mailing Address - Phone:239-309-6281
Mailing Address - Fax:
Practice Address - Street 1:1312 SE 17TH ST
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-4512
Practice Address - Country:US
Practice Address - Phone:239-309-6281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL111634400106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician