=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003680562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL MILESTONES THERAPHY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2023
-----------------------------------------------------
Last Update Date | 11/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4483 SW 8TH ST
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-2563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-975-8577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4483 SW 8TH ST
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-2563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-975-8577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MAIKEL Y PORTAL
-----------------------------------------------------
Credential | DNP,APRN,FNP-C,PMHNP
-----------------------------------------------------
Telephone | 305-316-9812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------