Provider Demographics
NPI:1104243997
Name:SARRIA FOURNIER, MAYTEBEL (SLPA)
Entity type:Individual
Prefix:
First Name:MAYTEBEL
Middle Name:
Last Name:SARRIA FOURNIER
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5860 W 18TH LN APT 101
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-8922
Mailing Address - Country:US
Mailing Address - Phone:786-262-8858
Mailing Address - Fax:
Practice Address - Street 1:556 NW 208TH WAY
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2154
Practice Address - Country:US
Practice Address - Phone:786-774-7729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLSI 2159235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-141059Medicaid