Provider Demographics
NPI:1194336990
Name:FERNANDEZ RODRIGUEZ, MIRLA
Entity type:Individual
Prefix:
First Name:MIRLA
Middle Name:
Last Name:FERNANDEZ RODRIGUEZ
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 1:8912 N TAMPA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-1354
Mailing Address - Country:US
Mailing Address - Phone:786-490-1079
Mailing Address - Fax:
Practice Address - Street 1:8912 N TAMPA ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-1354
Practice Address - Country:US
Practice Address - Phone:786-490-1079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-20-120202106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician