Provider Demographics
NPI:1891518247
Name:MONTANO CORDERO, IVAN JAVIER
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:JAVIER
Last Name:MONTANO CORDERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12850 SW 43RD DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4176
Mailing Address - Country:US
Mailing Address - Phone:615-828-3315
Mailing Address - Fax:
Practice Address - Street 1:12850 SW 43RD DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-4176
Practice Address - Country:US
Practice Address - Phone:615-828-3315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-364839106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician