Provider Demographics
NPI:1164239133
Name:LARA GOVANTES, MELANI
Entity type:Individual
Prefix:
First Name:MELANI
Middle Name:
Last Name:LARA GOVANTES
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 1:8893 FONTAINEBLEAU BLVD APT 203
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4432
Mailing Address - Country:US
Mailing Address - Phone:786-810-5332
Mailing Address - Fax:
Practice Address - Street 1:8893 FONTAINEBLEAU BLVD APT 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-4432
Practice Address - Country:US
Practice Address - Phone:786-810-5332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-399682106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician