Provider Demographics
NPI:1053057661
Name:BALZA, KLEYDIMAR DANIELA
Entity Type:Individual
Prefix:
First Name:KLEYDIMAR
Middle Name:DANIELA
Last Name:BALZA
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 1:230 NW 109TH AVE APT 217
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-5255
Mailing Address - Country:US
Mailing Address - Phone:786-832-9929
Mailing Address - Fax:
Practice Address - Street 1:230 NW 109TH AVE APT 217
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-5255
Practice Address - Country:US
Practice Address - Phone:786-832-9929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty