Provider Demographics
NPI:1962150045
Name:RENOVALES DELGADO, ELAINE
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:RENOVALES DELGADO
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 1:5590 W 14TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2233
Mailing Address - Country:US
Mailing Address - Phone:786-510-9356
Mailing Address - Fax:
Practice Address - Street 1:7975 NW 154TH ST STE 2230
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-5863
Practice Address - Country:US
Practice Address - Phone:305-874-7245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-129268106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician