Provider Demographics
NPI:1124775473
Name:POLO SOSA, MAIYEN
Entity type:Individual
Prefix:
First Name:MAIYEN
Middle Name:
Last Name:POLO SOSA
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 1:13201 SW 200TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-6150
Mailing Address - Country:US
Mailing Address - Phone:305-898-2421
Mailing Address - Fax:
Practice Address - Street 1:12150 SW 128TH CT STE 108
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4648
Practice Address - Country:US
Practice Address - Phone:786-732-0607
Practice Address - Fax:786-732-0637
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-81803106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician