=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700740388
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAITE VILLAR FERNANDEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2025
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1395 SW 46TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33317-6804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-508-6765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1395 SW 46TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33317-6804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-508-6765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT25493844
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------