Provider Demographics
NPI:1962266429
Name:VALDIVIA JIMENEZ, YUDISLEIVY
Entity type:Individual
Prefix:
First Name:YUDISLEIVY
Middle Name:
Last Name:VALDIVIA JIMENEZ
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 1:13801 NW 4TH ST APT 107
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2273
Mailing Address - Country:US
Mailing Address - Phone:786-714-7758
Mailing Address - Fax:
Practice Address - Street 1:6801 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2955
Practice Address - Country:US
Practice Address - Phone:616-607-6675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-325358106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician