Provider Demographics
NPI:1730704180
Name:ALFONSO, DIAMANTE ROSA (RBT)
Entity type:Individual
Prefix:
First Name:DIAMANTE
Middle Name:ROSA
Last Name:ALFONSO
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 1:8359 BEACON BLVD STE 416
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33993-2300
Practice Address - Country:US
Practice Address - Phone:239-600-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT20121212106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107175400Medicaid