Provider Demographics
NPI:1851756464
Name:MOLINA MUTIZ, IRIS ALTAGRACIA
Entity type:Individual
Prefix:MS
First Name:IRIS
Middle Name:ALTAGRACIA
Last Name:MOLINA MUTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:IRIS
Other - Middle Name:ALTAGRACIA
Other - Last Name:MOLINA MUTIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7815 SW 88TH ST APT E326
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7729
Mailing Address - Country:US
Mailing Address - Phone:305-606-6195
Mailing Address - Fax:
Practice Address - Street 1:7473 SW 82ND ST APT A312
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-7353
Practice Address - Country:US
Practice Address - Phone:786-867-4376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-24
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-19-9759106E00000X
FLRBT-18-60572106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31224695Medicaid