Provider Demographics
NPI:1174201347
Name:HERNANDEZ FLEITAS, MAYDOLIS
Entity type:Individual
Prefix:
First Name:MAYDOLIS
Middle Name:
Last Name:HERNANDEZ FLEITAS
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 1:4975 SW 140TH TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6204
Mailing Address - Country:US
Mailing Address - Phone:305-300-7102
Mailing Address - Fax:
Practice Address - Street 1:4975 SW 140TH TER
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6204
Practice Address - Country:US
Practice Address - Phone:305-300-7102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-278852106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician