Provider Demographics
NPI:1194567602
Name:BERUVIDES, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:BERUVIDES
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 1:2614 NW 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-3234
Mailing Address - Country:US
Mailing Address - Phone:786-499-3295
Mailing Address - Fax:
Practice Address - Street 1:2614 NW 122ND AVE
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-3234
Practice Address - Country:US
Practice Address - Phone:786-499-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-4481-619855106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty