Provider Demographics
NPI:1003400052
Name:VALDEON MANTILLA, CRYSTAL MICHELLE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:VALDEON MANTILLA
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 1:210 FONTAINEBLEAU BLVD APT 512
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4573
Mailing Address - Country:US
Mailing Address - Phone:305-588-8846
Mailing Address - Fax:
Practice Address - Street 1:210 FONTAINEBLEAU BLVD APT 512
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-4573
Practice Address - Country:US
Practice Address - Phone:305-588-8846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-21
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-153423106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician