Provider Demographics
NPI:1174132252
Name:LUNA, MYRA JEAN (RBT)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:JEAN
Last Name:LUNA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CRISTOBAL ROAD
Mailing Address - Street 2:501
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569
Mailing Address - Country:US
Mailing Address - Phone:850-582-0089
Mailing Address - Fax:
Practice Address - Street 1:140 CRISTOBAL ROAD N
Practice Address - Street 2:SUITE 501
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569
Practice Address - Country:US
Practice Address - Phone:850-582-0089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-127879106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician