Healthcare Provider Details

I. General information

NPI: 1164344453
Provider Name (Legal Business Name): KETIA BARRERA REYES
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 NW 25TH ST STE 211
DORAL FL
33172-5927
US

IV. Provider business mailing address

1430 SW 126TH PL
MIAMI FL
33184-2310
US

V. Phone/Fax

Practice location:
  • Phone: 305-381-0346
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-472204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: