MEDICARE: MARIA LETICIA VERA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	103T00000X	Psychologist	FL
2	106S00000X	Behavior Technician
3	103TH0004X	Health Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V656552688040	OTHER	FL	DRIVER LICENSE

General Provider Information

NPI Number	:	1720590979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA LETICIA VERA

Provider Business Mailing Address
First Line	:	3113 STIRLING RD STE 204
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-6547
Country	:	US
Telephone Number	:	954-842-3501
Fax Number	:	954-206-0906

Provider Business Practice Location Address
First Line	:	3113 STIRLING RD STE 204
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-6547
Country	:	US
Telephone Number	:	954-842-3501
Fax Number	:	954-206-0906

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2017
Last Update Date	:	06/16/2018

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Directions to “ MARIA LETICIA VERA ” Practice Location

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