Healthcare Provider Details

I. General information

NPI: 1699624817
Provider Name (Legal Business Name): MIDORYS VIVIAN ROCHE SALAZAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 SW 197TH ST APT 202
CUTLER BAY FL
33157-8478
US

IV. Provider business mailing address

11050 SW 197TH ST APT 202
CUTLER BAY FL
33157-8478
US

V. Phone/Fax

Practice location:
  • Phone: 305-784-0039
  • Fax:
Mailing address:
  • Phone: 305-784-0039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-487634
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: