Provider Demographics
NPI:1366890790
Name:FERNANDEZ DE CASTRO, MARIA JULIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:JULIA
Last Name:FERNANDEZ DE CASTRO
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 1:20402 NW 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1234
Mailing Address - Country:US
Mailing Address - Phone:786-985-3386
Mailing Address - Fax:
Practice Address - Street 1:11890 SW 8TH ST STE 210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-1742
Practice Address - Country:US
Practice Address - Phone:786-534-8408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL106S00000X
FLRBT-15-04651103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102891500Medicaid