Provider Demographics
NPI:1548875602
Name:VELAZQUEZ ESTRADA, MIRTHA (RBT)
Entity type:Individual
Prefix:
First Name:MIRTHA
Middle Name:
Last Name:VELAZQUEZ ESTRADA
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 1:2201 W 64TH ST APT 203
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6930
Mailing Address - Country:US
Mailing Address - Phone:786-857-8167
Mailing Address - Fax:
Practice Address - Street 1:7925 NW 12TH ST STE 401
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1822
Practice Address - Country:US
Practice Address - Phone:786-615-4409
Practice Address - Fax:786-637-2974
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20117715106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician