MEDICARE: CRISTOBAL CLINIO MAYOLA ALBERTO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	23-286650	FL

General Provider Information

NPI Number	:	1154103539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRISTOBAL CLINIO MAYOLA ALBERTO

Provider Business Mailing Address
First Line	:	2377 W 66TH PL
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-3977
Country	:	US
Telephone Number	:	786-502-5232
Fax Number	:

Provider Business Practice Location Address
First Line	:	8852 W LONG ACRE DR
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33025-2742
Country	:	US
Telephone Number	:	786-502-5232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2023
Last Update Date	:	03/03/2026

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