Provider Demographics
NPI:1194599191
Name:GARCIA CABRERA, ILLENID
Entity type:Individual
Prefix:
First Name:ILLENID
Middle Name:
Last Name:GARCIA CABRERA
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 1:920 SE 6TH CT
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3508
Mailing Address - Country:US
Mailing Address - Phone:239-791-2312
Mailing Address - Fax:
Practice Address - Street 1:8270 BURNT STORE RD UNIT 3
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-4705
Practice Address - Country:US
Practice Address - Phone:941-456-0018
Practice Address - Fax:239-900-1995
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-304679106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician