Provider Demographics
NPI:1124521596
Name:NIEBLA RAYA, IVEISY
Entity type:Individual
Prefix:
First Name:IVEISY
Middle Name:
Last Name:NIEBLA RAYA
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 1:2912 NW 49TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-3557
Mailing Address - Country:US
Mailing Address - Phone:786-622-6497
Mailing Address - Fax:
Practice Address - Street 1:2912 NW 49TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-3557
Practice Address - Country:US
Practice Address - Phone:786-622-6497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108174500Medicaid