Provider Demographics
NPI:1306661038
Name:VIZCAINO DENIS, GRETTER
Entity type:Individual
Prefix:
First Name:GRETTER
Middle Name:
Last Name:VIZCAINO DENIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRETTER
Other - Middle Name:
Other - Last Name:VIZCAINO DENIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GRETTER VIZCAINO
Mailing Address - Street 1:2711 HIDDEN VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3347
Mailing Address - Country:US
Mailing Address - Phone:904-412-0685
Mailing Address - Fax:904-877-3674
Practice Address - Street 1:2711 HIDDEN VILLAGE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-3347
Practice Address - Country:US
Practice Address - Phone:904-412-0685
Practice Address - Fax:904-877-3674
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLV620-656-39-100-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician