Healthcare Provider Details

I. General information

NPI: 1801365630
Provider Name (Legal Business Name): MIDIALA HURTADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2018
Last Update Date: 11/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 N KROME AVE STE 206
HOMESTEAD FL
33030-6047
US

IV. Provider business mailing address

14329 SW 168TH TER
MIAMI FL
33177-2072
US

V. Phone/Fax

Practice location:
  • Phone: 786-410-8922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-18-61548
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: