Provider Demographics
NPI:1003698218
Name:DE LA MONEDA, MAGDIEL
Entity Type:Individual
Prefix:
First Name:MAGDIEL
Middle Name:
Last Name:DE LA MONEDA
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 1:18340 NW 62ND AVE APT 212
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-8208
Mailing Address - Country:US
Mailing Address - Phone:786-859-8793
Mailing Address - Fax:
Practice Address - Street 1:18340 NW 62ND AVE APT 212
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-8208
Practice Address - Country:US
Practice Address - Phone:786-859-8793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-210793106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120143400Medicaid