Provider Demographics
NPI:1104336635
Name:VIVAS, ODILIA D
Entity type:Individual
Prefix:
First Name:ODILIA
Middle Name:D
Last Name:VIVAS
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 1:9010 SW 8TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-3171
Mailing Address - Country:US
Mailing Address - Phone:786-853-4206
Mailing Address - Fax:
Practice Address - Street 1:1665 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4400
Practice Address - Country:US
Practice Address - Phone:786-773-3393
Practice Address - Fax:786-773-3394
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician