Provider Demographics
NPI:1720593361
Name:PUPO RONDON, TATIANA
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:PUPO RONDON
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 1:5751 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-1219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5751 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-1219
Practice Address - Country:US
Practice Address - Phone:305-917-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-20-11590106E00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician