Provider Demographics
NPI:1154138212
Name:MATHURIN, THERRY
Entity type:Individual
Prefix:
First Name:THERRY
Middle Name:
Last Name:MATHURIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NE 166TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3683
Mailing Address - Country:US
Mailing Address - Phone:786-273-1535
Mailing Address - Fax:
Practice Address - Street 1:725 NE 166TH ST APT 1
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33162-3683
Practice Address - Country:US
Practice Address - Phone:786-273-1535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1206016106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst