Healthcare Provider Details

I. General information

NPI: 1801653100
Provider Name (Legal Business Name): MILENY REQUEJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8491 NW 17TH ST STE 110
DORAL FL
33126-1025
US

IV. Provider business mailing address

8491 NW 17TH ST STE 110
DORAL FL
33126-1025
US

V. Phone/Fax

Practice location:
  • Phone: 305-305-9665
  • Fax: 786-598-7590
Mailing address:
  • Phone: 305-305-9665
  • Fax: 786-598-7590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-331468
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: