Provider Demographics
NPI:1295582492
Name:DORTA, JOSE DANIEL
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:DANIEL
Last Name:DORTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 GIULIANO AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3726
Mailing Address - Country:US
Mailing Address - Phone:561-907-2309
Mailing Address - Fax:
Practice Address - Street 1:2927 GIULIANO AVE
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-3726
Practice Address - Country:US
Practice Address - Phone:561-907-2309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-04
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-344030106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician