Provider Demographics
NPI:1063001543
Name:LARRONDO, MAIDELLET
Entity Type:Individual
Prefix:
First Name:MAIDELLET
Middle Name:
Last Name:LARRONDO
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 1:835 NW 45TH AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2595
Mailing Address - Country:US
Mailing Address - Phone:561-932-4807
Mailing Address - Fax:
Practice Address - Street 1:8100 NW 155TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-5865
Practice Address - Country:US
Practice Address - Phone:786-479-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-146958106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty