Healthcare Provider Details

I. General information

NPI: 1164148383
Provider Name (Legal Business Name): EDILKA MARIELA FRIAS FERNANDEZ RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 09/20/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19464 NW 30TH CT
MIAMI GARDENS FL
33056-2414
US

IV. Provider business mailing address

6380 RADIO RD LOT 32
NAPLES FL
34104-4171
US

V. Phone/Fax

Practice location:
  • Phone: 786-488-6629
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-143356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: