Provider Demographics
NPI:1104255090
Name:GAVIDIA, ODALIS
Entity type:Individual
Prefix:
First Name:ODALIS
Middle Name:
Last Name:GAVIDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7395 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4215
Mailing Address - Country:US
Mailing Address - Phone:786-269-8717
Mailing Address - Fax:
Practice Address - Street 1:11755 SW 90TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-2177
Practice Address - Country:US
Practice Address - Phone:305-846-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst