Provider Demographics
NPI:1730848250
Name:CORES MACIAS, INDIRA
Entity type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:CORES MACIAS
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 1:12320 SW 187TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-3114
Mailing Address - Country:US
Mailing Address - Phone:786-366-4981
Mailing Address - Fax:
Practice Address - Street 1:12320 SW 187TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-3114
Practice Address - Country:US
Practice Address - Phone:786-366-4981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136693106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110786400Medicaid