Healthcare Provider Details

I. General information

NPI: 1336993831
Provider Name (Legal Business Name): SAMANTHA LISSETHE MEZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 NW 25TH ST STE 5E
DORAL FL
33172-1416
US

IV. Provider business mailing address

7020 W 35TH AVE UNIT 102
HIALEAH FL
33018-7146
US

V. Phone/Fax

Practice location:
  • Phone: 888-527-8037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-327218
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: