Healthcare Provider Details

I. General information

NPI: 1568997450
Provider Name (Legal Business Name): MELVYS PENATE JUVIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2548 W 64TH PL
HIALEAH FL
33016-6318
US

IV. Provider business mailing address

2548 W 64TH PL
HIALEAH FL
33016-6318
US

V. Phone/Fax

Practice location:
  • Phone: 786-675-2023
  • Fax:
Mailing address:
  • Phone: 786-675-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-46053
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: