Provider Demographics
NPI:1861239170
Name:MEDEROS FERNANDEZ, MAIRET
Entity type:Individual
Prefix:
First Name:MAIRET
Middle Name:
Last Name:MEDEROS FERNANDEZ
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 1:200 SE 15TH RD APT 16A
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33129-1201
Mailing Address - Country:US
Mailing Address - Phone:305-339-1141
Mailing Address - Fax:
Practice Address - Street 1:200 SE 15TH RD APT 16A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33129-1201
Practice Address - Country:US
Practice Address - Phone:305-339-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-347392106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician