Provider Demographics
NPI:1417455627
Name:COREANO, LYNETTE
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:COREANO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 FESTIVO LN NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-5569
Mailing Address - Country:US
Mailing Address - Phone:321-514-8284
Mailing Address - Fax:
Practice Address - Street 1:1887 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5530
Practice Address - Country:US
Practice Address - Phone:772-463-0444
Practice Address - Fax:772-219-1339
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-22-63075103K00000X
FLRBT-18-61442106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023670400Medicaid