Healthcare Provider Details

I. General information

NPI: 1083004295
Provider Name (Legal Business Name): GREULY MENDOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NW 107TH AVE SUITE 200
DORAL FL
33172-5925
US

IV. Provider business mailing address

2500 NW 107TH AVE SUITE 200
DORAL FL
33172-5925
US

V. Phone/Fax

Practice location:
  • Phone: 305-597-3861
  • Fax: 305-503-9294
Mailing address:
  • Phone: 305-597-3861
  • Fax: 305-503-9294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: