Provider Demographics
NPI:1144715178
Name:TABAREZ, DAMARIS
Entity type:Individual
Prefix:
First Name:DAMARIS
Middle Name:
Last Name:TABAREZ
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 1:8760 NW 33RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-3900
Mailing Address - Country:US
Mailing Address - Phone:305-401-7947
Mailing Address - Fax:
Practice Address - Street 1:8801 NW 33RD COURT RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147
Practice Address - Country:US
Practice Address - Phone:305-401-7947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018165500Medicaid