Provider Demographics
NPI:1043034986
Name:VIVANCO, CARLOS (RBT)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:VIVANCO
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-2246
Mailing Address - Country:US
Mailing Address - Phone:786-942-1120
Mailing Address - Fax:
Practice Address - Street 1:501 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:FL
Practice Address - Zip Code:33403-3557
Practice Address - Country:US
Practice Address - Phone:561-284-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst