Provider Demographics
NPI:1396345369
Name:CASAS VAZQUEZ, MYLENA DE LA CARIDAD
Entity type:Individual
Prefix:
First Name:MYLENA DE LA CARIDAD
Middle Name:
Last Name:CASAS VAZQUEZ
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 1:2431 W 52ND PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4760
Mailing Address - Country:US
Mailing Address - Phone:305-345-0029
Mailing Address - Fax:
Practice Address - Street 1:12975 SW 132ND CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5820
Practice Address - Country:US
Practice Address - Phone:305-256-1653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-138644106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-138644OtherRBT