Provider Demographics
NPI:1104633767
Name:CEDENO BAUTA, THALIA (DO)
Entity type:Individual
Prefix:
First Name:THALIA
Middle Name:
Last Name:CEDENO BAUTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:THALIA
Other - Middle Name:
Other - Last Name:CEDENO BAUTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:301 HIALEAH DR APT 203
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-5259
Mailing Address - Country:US
Mailing Address - Phone:786-371-5861
Mailing Address - Fax:
Practice Address - Street 1:301 HIALEAH DR APT 203
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-5259
Practice Address - Country:US
Practice Address - Phone:786-371-5861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-395347106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician