Provider Demographics
NPI:1902408388
Name:ENRIQUE, IDANIA
Entity Type:Individual
Prefix:
First Name:IDANIA
Middle Name:
Last Name:ENRIQUE
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 1:65 W 60TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2628
Mailing Address - Country:US
Mailing Address - Phone:786-426-0453
Mailing Address - Fax:
Practice Address - Street 1:12485 SW 137TH AVE STE 106
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4215
Practice Address - Country:US
Practice Address - Phone:786-250-4423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-126288106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician