Provider Demographics
NPI:1528692597
Name:IBANEZ MOSTAJO, ESTELA M (BCBA)
Entity type:Individual
Prefix:
First Name:ESTELA
Middle Name:M
Last Name:IBANEZ MOSTAJO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6292 SEMINOLE TER
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-8344
Mailing Address - Country:US
Mailing Address - Phone:954-478-9757
Mailing Address - Fax:
Practice Address - Street 1:2873 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3603
Practice Address - Country:US
Practice Address - Phone:754-812-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-61279106S00000X
FL1-21-52827103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician