Provider Demographics
NPI:1417828476
Name:CARBONELL BUSTAMANTE, JOHNNATAN
Entity type:Individual
Prefix:
First Name:JOHNNATAN
Middle Name:
Last Name:CARBONELL BUSTAMANTE
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 1:4801 SABLE PINE CIR APT B1
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-3130
Mailing Address - Country:US
Mailing Address - Phone:561-817-7264
Mailing Address - Fax:
Practice Address - Street 1:4801 SABLE PINE CIR APT B1
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33417-3130
Practice Address - Country:US
Practice Address - Phone:561-817-7264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-472593106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician