Provider Demographics
NPI:1053917815
Name:BENCOSME, KYANNA ADRIANA
Entity type:Individual
Prefix:
First Name:KYANNA
Middle Name:ADRIANA
Last Name:BENCOSME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 SE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2604
Mailing Address - Country:US
Mailing Address - Phone:239-220-1229
Mailing Address - Fax:
Practice Address - Street 1:1775 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5067
Practice Address - Country:US
Practice Address - Phone:407-919-6845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician