Provider Demographics
NPI:1316603038
Name:CORNELIO, HEIDDY
Entity type:Individual
Prefix:
First Name:HEIDDY
Middle Name:
Last Name:CORNELIO
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 1:355 NW 72ND AVE APT 405
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4310
Mailing Address - Country:US
Mailing Address - Phone:786-663-5644
Mailing Address - Fax:
Practice Address - Street 1:355 NW 72ND AVE APT 405
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4310
Practice Address - Country:US
Practice Address - Phone:305-263-0207
Practice Address - Fax:786-364-1944
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-121015106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician