Provider Demographics
NPI:1629889753
Name:MATA TORNAVACA, DAYLONSI
Entity type:Individual
Prefix:
First Name:DAYLONSI
Middle Name:
Last Name:MATA TORNAVACA
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 1:11840 NE 19TH DR APT 27
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-2848
Mailing Address - Country:US
Mailing Address - Phone:786-337-0090
Mailing Address - Fax:
Practice Address - Street 1:11840 NE 19TH DR APT 27
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-2848
Practice Address - Country:US
Practice Address - Phone:786-337-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-400850106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty