Provider Demographics
NPI:1174325120
Name:BRICENO, ILSE J
Entity type:Individual
Prefix:
First Name:ILSE
Middle Name:J
Last Name:BRICENO
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 1:12342 SW NETTUNO WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-5436
Mailing Address - Country:US
Mailing Address - Phone:772-207-9970
Mailing Address - Fax:
Practice Address - Street 1:1401 SE GOLDTREE DR STE 101
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7584
Practice Address - Country:US
Practice Address - Phone:772-212-7539
Practice Address - Fax:772-673-8392
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-412806106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician