Provider Demographics
NPI:1588412506
Name:FERNANDEZ MATOS, DANIELA (RBT-24-343718)
Entity type:Individual
Prefix:
First Name:DANIELA
Middle Name:
Last Name:FERNANDEZ MATOS
Suffix:
Gender:F
Credentials:RBT-24-343718
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 REGENCY ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-5058
Mailing Address - Country:US
Mailing Address - Phone:863-378-5879
Mailing Address - Fax:
Practice Address - Street 1:314 REGENCY ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-5058
Practice Address - Country:US
Practice Address - Phone:863-378-5879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-343718106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician