Provider Demographics
NPI:1174153563
Name:MONTESINO GARCIA, VIVIANA
Entity type:Individual
Prefix:
First Name:VIVIANA
Middle Name:
Last Name:MONTESINO GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14170 PADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-7828
Mailing Address - Country:US
Mailing Address - Phone:561-729-9316
Mailing Address - Fax:
Practice Address - Street 1:6415 LAKE WORTH RD STE 204
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-2904
Practice Address - Country:US
Practice Address - Phone:561-771-9561
Practice Address - Fax:800-766-3139
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2024-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-110764106S00000X
FL1-21-54061103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105779400Medicaid