Healthcare Provider Details

I. General information

NPI: 1144762667
Provider Name (Legal Business Name): TATIANA MIJARES-CANTRELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TATIANA MIJARES LCSW

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SW 216TH ST
CUTLER BAY FL
33190-1003
US

IV. Provider business mailing address

10300 SW 216TH ST
CUTLER BAY FL
33190-1003
US

V. Phone/Fax

Practice location:
  • Phone: 305-253-5100
  • Fax:
Mailing address:
  • Phone: 305-253-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13990
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSW13990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: