Provider Demographics
NPI:1386254175
Name:TAQUECHEL MEDINA, YARAIDY
Entity type:Individual
Prefix:
First Name:YARAIDY
Middle Name:
Last Name:TAQUECHEL MEDINA
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 1:11790 SW 18TH ST APT 204
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-1649
Mailing Address - Country:US
Mailing Address - Phone:321-419-5125
Mailing Address - Fax:
Practice Address - Street 1:11790 SW 18TH ST APT 204
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-1649
Practice Address - Country:US
Practice Address - Phone:321-419-5125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-130451106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician