MEDICARE: MAYDELIS ROSA AVILA LOPEZ

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		FL

General Provider Information

NPI Number	:	1962209676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYDELIS ROSA AVILA LOPEZ

Provider Business Mailing Address
First Line	:	777 NW 72ND AVE STE 1083
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-3176
Country	:	US
Telephone Number	:	786-490-6307
Fax Number	:

Provider Business Practice Location Address
First Line	:	6364 E 5TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33013-1116
Country	:	US
Telephone Number	:	786-278-9843
Fax Number	:

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

Provider Enumeration Date	:	02/28/2025
Last Update Date	:	02/28/2025

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