Provider Demographics
NPI:1962211508
Name:SIERRA MATOS, MAIKELIN
Entity type:Individual
Prefix:
First Name:MAIKELIN
Middle Name:
Last Name:SIERRA MATOS
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 1:2158 PRADO DR APT 43
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-5850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2158 PRADO DR APT 43
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-5850
Practice Address - Country:US
Practice Address - Phone:909-665-2632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-401123106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician