Provider Demographics
NPI:1205718095
Name:VIVENES, NIDIS
Entity type:Individual
Prefix:
First Name:NIDIS
Middle Name:
Last Name:VIVENES
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 1:1281 NE 117TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33161-6829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4385 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7628
Practice Address - Country:US
Practice Address - Phone:305-824-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-22
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW19306101YM0800X, 101YS0200X, 1041S0200X, 221700000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist