Provider Demographics
NPI:1548085871
Name:JUSTINIANO, MADISON MARIE-AGLAE (RBT)
Entity type:Individual
Prefix:MISS
First Name:MADISON
Middle Name:MARIE-AGLAE
Last Name:JUSTINIANO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 ROSS LANIER LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-2135
Mailing Address - Country:US
Mailing Address - Phone:347-669-6080
Mailing Address - Fax:
Practice Address - Street 1:102 PARK PLACE BLVD STE C1
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2358
Practice Address - Country:US
Practice Address - Phone:407-385-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-394652106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician