Provider Demographics
NPI:1902246143
Name:BAJUELO, DAINE E
Entity type:Individual
Prefix:
First Name:DAINE
Middle Name:E
Last Name:BAJUELO
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 1:30304 SW 151ST AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3748
Mailing Address - Country:US
Mailing Address - Phone:786-597-2609
Mailing Address - Fax:
Practice Address - Street 1:30304 SW 151ST AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-3748
Practice Address - Country:US
Practice Address - Phone:786-597-2609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
221700000X
FL390200000X
FL19-77039106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program