Provider Demographics
NPI:1992496822
Name:VISTOSO, LUCA NAVARRO
Entity type:Individual
Prefix:
First Name:LUCA
Middle Name:NAVARRO
Last Name:VISTOSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANASTASIA
Other - Middle Name:MARIA
Other - Last Name:VISTOSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:718-865-5165
Practice Address - Street 1:7103 MILFORD INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-6061
Practice Address - Country:US
Practice Address - Phone:718-215-5311
Practice Address - Fax:718-865-5165
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician